Cclmtibia  ^ntbtr^f+- 


^tUvmtt  Htbrarg 

^xnftt  by 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofstomacOOhemm 


ation  of  fre« 
**mU  of  cylindn- 
oal   rpitJxOiiiin. 


Small  rHiMllaiy 
•ein  in  llif  iiit.-r- 
K'landiilar  con- 
nective tiiwuo, 

fii-Kt  and 
seconil   t;lnn<l 
tuhuie. 


bet 


Capillary. 


Small  vein  ari»- 
inK  from  musen- 

tariH  mncoKai* 

in  Pi'ntor  of   the 

drawinff. 


Cylindrical  epi- 
thelinm  of  th« 
(rnstric  surface 


Vestibule 
(.Vornmni.) 


VERTICAL  .SECTION  THROUGH  NORMAL  HUMAN 
GASTRIC  MUCOSA. 


DISEASES 


STOMACH 


THEIR     SPECIAL     PATHOLOGY,    DIAGNOSIS,    AND     TREATMENT, 
WITH  SECTIONS   ON  ANATOMY,   PHYSIOLOGY,   CHEMI- 
CAL AND    MICROSCOPICAL  EXAMINATION    OF 
STOMACH  CONTENTS,  DIETETICS,  SUR- 
GERY OF  THE  STOMACH,  ETC. 


IN    THREE   PARTS 


JOHN    C.  HEMMETER,    M.D.,  Philos.D. 

CLINICAL    PROFESSOR    OF   MEDICINE    IN  THE    UNIVERSITY   OF    MARYLAND,  BALTIMORE;     CONSULTANT   TO 
THE  UNIVERSITY  HOSPITAL,    AND    DIRECTOR   OF  THE   CLINICAL   LABORATORY,    ETC. 


WITH    MANY    ORIGINAL    ILLUSTRATIONS 

A  NUMBER   OF   WHICH  ARE  IN  COLORS 

AND    A    LITHOGRAPH    FRONTISPIECE 


PHILADELPHLA 

R    BLAKISTON,    SON    &    CO, 

IOI2      WALNUT      STREET 
1898 


Copyright,  1897,  by  P.  Blaktston,  Son  &  Co. 


Press  of  Wm.  F.  Fell  &  Co., 

1220-24  Sansom  St., 

philadelphia. 


THE    BELLY  AND  THE   MEMBERS 


The  members  of  the  body  rebelled  against  the  Belly,  and 
said,  "Why  should  we  be  perpetually  engaged  in  administer- 
ing to  your  wants,  while  you  do  nothing  but  take  your  rest 
and  enjoy  yourself  in  luxury  and  self-indulgence?"  The 
members  carried  out  their  resolve,  and  refused  their  assistance 
to  the  Belly.  The  whole  body  quickly  became  debilitated, 
and  the  hands,  feet,  mouth,  and  eyes,  when  too  late,  repented 
of  their  folly. — j^sop. 


TO 

PROFESSOR  WILLIAM   OSLER,  M.D. 

OF    BALTIMORE. 

II  maestro  di  color  che  sanno. — Dante. 

THIS     VOLUME     IS     RESPECTFULLY 
DEDICATED. 


PREFACE. 


The  tendency  of  modern  science — not  only  of  medical  science — 
is  toward  specialization. , 

Diseases  of  the  stomach  alone  is  not  a  field  sufficiently  large  to 
constitute  a  genuine  specialty.  It  is  generally  associated  with  the 
study  of  the  diseases  of  all  digestive  organs,  particularly  of  the 
intestines,  liver,  and  pancreas.  The  diseases  of  metabolism  consti- 
tute a  legitimate  field  naturally  falling  into  the  domain  of  the 
digestive  clinical  pathologist. 

In  an  address  before  the  iNIedical  and  Chirurgical  State  Faculty 
of  Maryland  in  April,  1896,  Professor  Da  Costa,  in  speaking  of  the 
manner  in  which  medical  libraries  build  up  and  increase,  said  that 
"  books  attract  books,  and,  as  a  rule,  any  new  work  in  any  par- 
ticular class  has  a  striking  family  resemblance  to  those  already 
published." 

If  this  new  contribution  to  the  pathology  and  treatment  of 
organic  diseases  of  the  stomach  does  not  conform  to  Da  Costa's 
generalization,  it  is  not  because  of  any  premeditated  plan  to  make 
it  different  from  other  works  on  the  same  subject,  but  because  a 
number  of  entirely  new  methods  of  diagnosis  have  entered  into  it, 
and  because  an  attempt  has  been  made  to  do  justice  to  the  work  of 
American  clinicians  in  this  special  department.  My  chief  effort 
has  been  to  furnish  the  general  practitioner  with  a  work  from 
which  he  can  readily  acquaint  himself  with  all  that  has  been  done 
in  this  important  branch  of  medicine,  to  fit  himself  to  make  ex- 
aminations, to  take  advantage  of  new  methods  of  diagnosis,  and 
to  treat  this  very  difficult  class  of  diseases  rationally  and  success- 
fully. 

With  this  end  in  view  I  have  endeavored  to  treat  the  subject 
systematically  and  concisely,  giving  first  the  special  anatomy  and 
physiology  of  the  digestive  organs,  methods  of  diagnosis  and 
general  therapy,  including  dietetics,  following  this  by  a  methodical 
discussion  of  the  various  diseases  affecting  the  stomach,  with  their 

vii 


viii  PREFACE. 

symptomatology,  diagnosis,  prognosis,  pathology,  and  treatment. 
The  illustrations,  of  which  many  are  from  original  drawings,  have 
been  selected  because  of  their  practical  bearing  upon  the  matter  in 
hand. 

Aside  from  the  fact  that  the  pathology,  diagnosis,  and  therapy 
of  diseases  of  the  human  organs  have  become  so  extensive  that  it 
is  absolutely  impossible  for  one  mind  to  master  them  all,  genuine 
advances  in  any  particular  department  have  hitherto  been  made 
only  by  such  scholars  as  could  concentrate  and  focus  their  mental 
energy  upon  a  limited  subject. 

Experience  of  the  last  twenty-five  years  has  demonstrated  that 
the  general,  fundamental  stock  of  medical  knowledge  has  not  been 
injured,  but,  on  the  contrary,  it  has  been  wonderfully  enlarged  and 
strengthened  by  the  progress  in  strictly  special  fields  of  work. 

To  read  the  history  of  the  development  of  medical  sciences,  the 
frequently  astonishing  results  and  indefatigable  perseverance  of 
"  the  grand  old  men  of  medicine,"  is  not  only  a  healthy  training 
for  prospective  investigators,  but  can  not  fail  to  polish  down  the 
pride  of  the  overambitious. 

Speaking  purely  from  a  therapeutic  standpoint,  however,  our 
medical  ancestors  of  the  beginning  of  this  century  were  for  the 
greater  part  divided  into  two  extreme  classes  :  First,  the  poly- 
pharmacists;  second,  the  skeptics,  the  therapeutic  nihilists.  It  is 
largely  the  credit  of  the  specialties  that  Asclepiads  have  evolved 
from  this  confused  opposition.  It  was  an  unspeakable  comfort  to 
be  reassured  by  Virchow  and  others  that,  after  all,  the  end-object, 
the  fundamental  purpose,  of  all  medical  progress,  must  be  the  relief 
of  suffering  and  the  cure  of  disease,  not  simply  the  development 
of  abstract  science.  A  further  step  in  the  evolution  of  therapy 
was  the  realization  that  the  object  of  medical  study  and  treatment 
must  not  be  the  "  disease,"  but  the  diseased  patient.  Specialties 
can  not  make  the  adept  one-sided,  nor  obscure  his  view  of  the 
general  body  of  medical  knowledge  ;  on  the  contrary,  the  detailed 
development  of  the  intellect  which  results  from  concentration  of 
energy  upon  one  subject  will  enlarge  his  powers  of  observation 
and  analysis  and  insure  a  more  comprehensive  understanding  of 
the  totality  of  general  medicine.  Boerhaave  could  claim  to  be 
master  of  all  applied  medical  branches;  Langenbeck  and  Frerichs 
were  credited  with  absolute  mastership  in  three  or  four  hetero- 
geneous branches  of  medicine.    Medicine  has  been  enormously  de- 


PREFACE.  IX 

veloped  since  those  days.  Who  will  claim  such  mastery  at 
the  present  time  ?  Bach,  Mozart,  and  Haydn  were  acknowledged 
virtuosi  on  five  or  six  instruments.  Where  is  such  a  phenomenal 
genius  of  the  present  day  in  music  ?  The  enlargement  of 
any  branch  of  human  knowledge  or  art  brings  specialization  with 
it  as  a  natural  sequence  ;  that  this  tendency  is  a  blessing  for  the 
central  fundamental  stock  of  knowledge,  science,  or  art  has  been 
proven  in  many  branches.  Perhaps  as  good  an  evidence  of  this 
fact  as  any  is  the  advantage  which  general  medicine  is  just  begin- 
ning to  reap  from  the  brilliant  results  of  bacteriology. 

When  the  printing  of  this  book  was  begun,  there  was  no  work 
of  American  origin  on  this  subject.  Since  then  the  volume  by 
Einhorn  has  appeared,  being  a  compilation  of  the  monographs  by 
this  author  in  the  "Twentieth  Century  Practice  of  Medicine." 

We  already  have  a  large  number  of  eminently  qualified  and 
versatile  clinicians,  men  with  acute  observing  powers  and  analytical 
minds,  who  have  worked  in  this  interesting  field.  The  names  of 
Austin  Flint,  Pepper,  Osier,  and  Delafield  are  as  well  known  in 
this  department  in  our  country  as  those  of  Kussmaul,  Senator, 
Nothnagel,  Leube,  Ewald,  and  Boas  in  Germany,  or  Hayem, 
Bouveret,  Debove,  and  Mathieu  in  France. 

Among  those  who  have  made  contributions  of  note  to  this  special 
line  of  work  are,  in  addition  to  Einhorn,  George  Dock,  W.  D. 
Booker,  Charles  G.  Stockton,  Allen  Jones,  D.  D.  Stewart,  Julius 
Friedenwald,  Francis  P.  Kinnicut,  Charles  E.  Simon,  and  other 
gifted  experimenters  and  observers. 

The  anatomy  of  the  stomach  has  received  a  lasting  benefit 
through  the  intellect  of  F.  Mall,  of  Baltimore. 

The  surgery  of  the  alimentary  tract  has  many  very  creditable 
representatives  in  our  country,  among  whom  may  be  mentioned 
Robert  F.  Weir,  N.  Senn,  John  B.  Deaver,  McBurney,  Roswell 
Park,  F.  Lang,  R.  Abbe,  W.  Meyer,  Murphy,  Bull,  Maurice  H. 
Richardson,  Gerster,  and  John  M.  T.  Finney.  The  literary  and 
practical  contributions  of  a  number  of  these  men  have  reached 
a  classic  standard  and  compelled  foreign  admiration. 

The  physiological  chemistry  of  digestion  and  internal  secretion 
has  received  the  benefit  of  the  work  of  Bowditch,  Chittenden, 
Howell,  Vaughn,  Adami,  Able,  and  others,  and  dietetics  has  its 
versatile  representative  in  Gilman  Thompson. 

To  Messrs.  Blakiston,  Son  &  Co.,  the  publishers,  the  author  feels 


X  PREFACE. 

sincerely  grateful.  It  would  be  a  neglect  to  omit  an  expression  of 
this  feeling.  The  manner  in  which  they  have  executed  their  part 
of  the  work  speaks  for  itself.  It  is  a  great  pleasure  for  an  author 
to  be  able  to  work  with  such  intelligent  and  enthusiastic  pub- 
lishers. 

To  Dr.  Edward  L.  Whitney,  my  associate,  it  becomes  my 
pleasant  duty  to  e.xpress  thanks  for  the  able  manner  in  which  he 
has  written  the  chemical  section  of  part  first,  and  also  for  much 
kind  assistance  throughout  the  work. 

Pathology  has  its  men  now  universally  acknowledged  for  the 

integrity  and  dignity  of  their  work  in  our  esteemed  teachers,  Welch 

and  Councilman.     Already  an  American  School  of  Pathology  is 

forming,  with  these  men  and  Prudden,  Flexner,  and  others.     But 

in  the  special  pathology  of  the  digestive    organs  the  workers  are 

few;  a  very  creditable  beginning,  however,  has  been  made;  the 

foundation  is  an  honor  to  the  prospective  builders,  but  the  land  to 

be  explored  is  exceedingly  large  in  its  extent,  and  ''  the  harvest  is 

plenteoiis,  bitt  the  laborers  are  fezv." 

JOHN  C.  HEMMETER. 
Baltimork,  1S97. 


'  Heard  are  the  voices, 
Heard  are  the  sages, 
The  worlds  and  the  ages  ; 
Choose  well,  your  choice  is 
Brief  and  yet  endless. 

'  Here  eyes  do  regard  you 
In  eternity's  stillness, 
Here  is  all  fullness. 
Ye  brave,  to  reward  you  ; 
Work  and  despair  not." 

— Goethe. 


LIST  OF   ILLUSTRATIONS. 


Normal  Histology  of  the  Gastric  Mucosa, Frontispiece 

I.   Three  Sections  of  Stomach-walls  Placed  Side  by  Side  to  Show  the  Positions  of 
Blood-vessels  and  Lymphatics  to  the  Different  Layers,     .    .    .   Facing  Page  28 
II.   Reconstruction    of     a    Small    Portion    of     the    I^Iiddle    Zone  of    the    Stomach 

Follows  Plate  I 

III.  Patient  with  Intragastric  Bag  within   Stomach  and  Pneumograph  in  Place,  Both 

Connected  with  the  Kymograph, Opposite  Page  74 

IV.  Apparatus,  not  Including  Kymograph, Follows  Plate  III 

Double  Plate  of  Tracings,  being  Records  of  Hemmeter's  Gastrograph, 

Between  Pages  78  and  79 
V.    Phlegmonous  Gastritis  in  the  Sequence  of  Ulcus  Carcinomatosum, 

Opposite  Page  410, 
VI.   Bacterial  Invasion  of  Gastric  Epithelium.     From  a  Case  of  Diphtheric   Gastritis 

Facing  Page  414 

W\.   Carcinomatous  Ulcer  of  the  Pyloric  Antrum, Facing  Page  464 

VIII.   Ulcus  Carcinomatosum  of  the  Pylorus, Facing  Page  478 

IX.   Syphilitic  Gastritis,  Showing  Degeneration  and  Loss  of  the  Superficial  Columnar 

Epithelium  and  that  of  the  Vestibules,  etc.,      Opposite  Page  554 

X.   Gastrectasia.     Transillumination  of  the  Stomach, Facing  Page  588 


Fig.  Page 

1—3.   Sections  of  Deep  Ends  of  Fundus  Glands  of  the  Cat  in  Different  Secretive 

Phases, 26 

4.  Plaster  Cast  of  Duodenum  of  Infant  and  Adult  (From  Mtiseum  of  Ha7-va7-d 

University.'), 40 

5.  Hemmeter's  Apparatus  for  Obtaining  Duodenal  Contents, 54 

6.  Pressure  Bottles  for  Distending  the  Intragastric  Bag  during  Duodenal  Intuba- 

tion,       55 

7.  Author's  Intragastric  Tissue  Rubber  Bag,  with  Three  Distinct  Parts,     ....  81 

8.  Location  of  the  Stomach — Dorsal  View, 98 

9.  Location  of  the  Stomach — Anterior  View, 99 

10.  Normal  Percussion  Limits  of  the  Adult  Stomach, loO 

11.  The  Electrodiaphane, 103 

12.  Hemmeter's  Double-current  Stomach  Lavage  Tube, 106 

13.  Illustrating  the  Principle  of  Siphonage,       107 

14.  Bulb  used  for  the  Aspiration  of  Test-meals  with  Patients  having  ver}'  Relaxed 

Abdominal  Walls, 107 

15.  Ewald  Stomach-tube, Iio 

xi 


XU  LIST    OF    ILLUSTRATIONS. 

Fig.  Page 

16.  The  Esophageal  Tubal  Probe,      ...Ill 

17.  Stomach-pump  used  only  for  Rapid  Evacuation  of  Poisons, 113 

18.  Modified  Ewald  Tube,  witli  Numerous  Smaller  and  Larger  Lower  Openings,  .  I14 

19.  Oppler-Boas  Bacillus  from  Contents  of  a  Carcinomatous  Stomach, I19 

20.  Fragment  of  Mucosa  showing  a  Normal  Condition  of  Glands, 130 

21.  Hypertrophy  and  Proliferation  of  Glandular  Elements, 131 

22.  Atrophy  and  Vacuolization  of  Glandular  Elements,  etc., 133 

23.  Strauss'  Mixing  Funnel  for  Lactic  Acid  Determinations, 160 

24.  Gastroscope, 171 

25.  Esophagoscope,  Obturator,  Esophageal  Forceps,  Esophageal  Applicator,      .    .  175 

26.  Recurrent  Gastric  Needle  Spray  or  Douche, 287 

27.  The  Intragastric  Spray, 288 

28.  Rectal  Electrode, 291 

29.  Einhorn's  Intragastric  Electrode, 291 

30.  Abdominal  Electrode, 295 

31.  Massage  of  the  Stomach  in  Dilatation  or  Gastroptosis,      297 

32.  Massage  for  Improving  Gastric  Tonicity, 298 

33.  Massage  of  the  Stomach  and  of  the  Colon, 298 

34.  Atrophy  and  Vacuolization  of  Glandular  Elements,  etc., 428 

35.  Cancerous  Invasion  of  the  Glandular  Layer.     A  Portion  of  the  Mucous  Coat,  493 

36.  Cancerous  Infiltration  of  the  Muscularis.      Section  of  a  Portion  of  the  Muscular 

Coat  of  the  Stomach, 494 

37.  A  Portion  of  an  Area  in  the  Submucosa,  Largely  Composed  of  Groups  of  Cancer 

Cells, 496 

38.  Section  of  Tissue  near  the  Base  of  a  Carcinomatous  Ulcer,   showing   Micro- 

organisms,   497 

39.  Dilatation  of  the  Stomach, 585 

40.  Histological  State  of  the  Glandular  Layer  in  Hyperacidity, 716 


TABLE   OF   CONTENTS. 


PART    FIRST. 


ANATOMY  AND  PHYSIOLOGY  OF  THE  DIGESTIVE   ORGANS. 
METHODS  AND  TECHNICS   OF   DIAGNOSIS. 


CHAPTER    I.  Page 

Anatomy  of   the  Stomach,      17-24 

Muscular  Layer. — Structure  of  the  Mucous  Membrane. — Three  Kinds 
of  Cells  of  the  Peptic  Glands. 

CHAPTER  n. 

Histology  of  the  Stomach, 25-31 

Mucosa. — Vessels  and  Nerves. 

CHAPTER  HI. 
The  Small  Intestine, 32-42 

Structure.  —  Valvulse  Conniventes. — Villi. — Lacteal  Glands. — The 
Blood-vessels. — Lymph- vessels. — Relations  of  the  Duodenum. — Jeju- 
num and  Ileum. 

CHAPTER  IV. 
Physiology  of  Digestion, 43-5° 

Food  Substances. — Caloric  Values. — Ptyalin  Digestion. — Digestion  of 
Starches. — Gastric  Juice. 

CHAPTER  V. 

Pepsinogen  and  Pepsin. — Rennin  Zymogen  and  Rennin. — 

Intestinal  Digestion. — Duodenal  Intubation,  .    .         51-59 

Physiology  of  Intestinal  Digestion. — The  Pancreas,  Its  Secretion  and 
Pancreatic  Digestion. 

CHAPTER  VI. 
The  Bile, 60-65 

The  Succus  Entericus. — Intestinal  Fennentation.  —  Putrefaction. — 
Formed  or  Organized  Ferments  (Bacteria). 

CHAPTER  VII. 

Effects  of   Contemporaneous  Action  of  Several  Dices-   ^ 
TivE    Secretions.  —  Methods     for     Testing     the 
Motor  Functions  of  the  Stomach, 66-72 

Qualitative  and  Quantitative  Methods  for  Testing  the  Motor  Functions 
of  the  Stomach. 

xiii 


XIV  TABLE    OF    CON'TENTS. 

CHAPTER   VIII.  Page 

Methods  for  Testing  the  Gastric  Peristalsis,     ....         73-79 

CHAPTER  IX. 

Hemmeter's   Method    for    Testing    the   Gastric   Peris- 
talsis,            80-90 

Theories  Concerning  the  ^Movements  of  the  Ingesta. 

CHAPTER  X. 
Absorption  from  the  Stomach,      91-96 

Penzoldt's  and  Faber's,  Herschel's,  Julius  Miller's,  and  Hemmeter's 
Tests  for  Gastric  Resorption. 

CHAPTER    XI. 

Methods    for    Determining    the    Location,     Size,    and 

Capacity  of  the  Stomach, 97-104 

Percussion  and  Palpation. — Gastrodiaphany  of  Einhorn. 

CHAPTER  XII. 
The  Stomach-tube  and  Technics  of  its  Introduction,    .     105-116 

Examination  of  Stomach  Contents. — Test-meals:  Their  Effects  upon 
the  Amount  of  Acid  Secreted. — Literature. 

CHAPTER  XIII. 

Methods  for  Qualitative  and  Quantitative  Analysis  of 

Stomach  Contents, 11 7-1 28 

Presence  of  Bits  of  Gastric  Mucosa. — Examination  of  Stomach  Con- 
tents for  Mucus,  Saliva,  Bile,  Duodenal  Secretions,  Blood,  and  Pus. — 
Tests  for  Blood  in  Stomach  Contents. — Demonstration  of  the  Presence 
of  Iron  in  the  Stomach  Contents  or  Vomited  Matter. — Spectroscopic 
E.\amination  of  Stomach  Contents  for  Blood. — Examinations  of  Por- 
tions of  Mucosa  or  Tissue  Found  in  the  Wash- water  and  Vomited 
Matter. — Literature. 

CHAPTER  XIV. 

The  Diagnostic  Significance  of    Fragments   of    Gastric 

Mucosa,    . 129-137 

Deductions  from  36  Cases. 

CHAPTER  XV. 
Occurrence  of  Secretions  in  the  Empty  Stomach,  .    .    .     138-146 

Stimulations  to  Secretions  of  Gastric  Juice. — Significance  of  Foam. — 
Preparation  of  Gastric  Contents. — Quantitative  Analysis. — Methods. — 
Standard  or  Normal  Solutions. — Indicators. — Titration. — Apparatus. 

CHAPTER  XVL 
Chemical  Examination  of  Gastric  Juice, 147-154 

Tests  for  Presence  of  Free  Acids. — Tests  for  Free  Hydrochloric  Acid. — 
The  Dimethyl-Amido-Azo-Benzol  Test. — The  Resorcin  Test. — Com- 
bined Hydrochloric  Acid. — Lactic  Acid  :  Formation,  Significance,  and 
Detection. 


TABLE    OF    CONTENTS.  XV 

CHAPTER  XVII.  Page 

Quantitative  Analysis  of  the  Stomach  Acids,     ....     155-162 

Topfer's,  Martius  and  Liittke,  and  Leo's  Methods. — Lactic  Acid  Quan- 
titative Estimation. — Fatty  and  Total  Organic  Acids. 

CHAPTER  XVIII. 

Digestive    Ferments. — Products    of     Digestion. — Tests 

FOR  Same, 163-169 

Saliva. — Pepsin. — Pepsinogen. — Rennin  and  Rennin  Zymogen. — Ac- 
tion of  Pepsin  on  Proteids. 

CHAPTER  XIX. 
Gastroscopv, 170-176 

Description  of  the  Instrument. 


PART    SECOND. 


THERAPY    AND   MATERIA   MEDICA   OF   STOMACH   DISEASES. 


CHAPTER  I. 

The    Principles    of    Dietetic    Treatment    of     Gastric 

Diseases,      177-218 

Preparations  of  the  Foods.- — The  Dietetics  of  Gastric  Ulcer  and  Ero- 
sions.— The  Indications  for  Predigested  Foods  :  Peptones,  Albumoses, 
Dextrose,  etc. — Rectal  Alimentation. — The  Occurrence  of  Proteohtic 
Ferments  in  the  Colon  and  Rectal  Contents.— Preparation  of  Rectal 
Enemata. — Indications  Necessitating  Rectal  Feeding. — Tables  of 
Dietetics. 

CHAPTER  II. 
Dietetic  Kitchen.     Diet  Lists, 219-273 

Indications  of  the  Palate. — Dietetical  Cooking. 

CHAPTER  III. 

The  Dietetics  of  x\lcohol  and  Alcoholic  Beverages,     .     274-284 

Action  of  Alcohol  on  Pancreatic  Digestion. — On  Salivary  Digestion. 

CHAPTER  IV. 
Lavage  axd  the  Gastric  Douche, 285-299 

The  Gastric  Douche. — Electricity  in  the  Treatment  of  Gastric  Diseases. 
- — Hydrotherapeutic  and  Orthopedic  Methods. — Gastric  Massage. 

CHAPTER  V. 
Mineral   Springs, 300-315 

The  Uses  and  Abuses  of  Natural  ]\Iineral  Waters  in  Diseases  of  the 
Digestive  Organs.- — Useful  Mineral  Springs  of  the  United  States,  with 
Analyses  and  Mode  of  Action. 


XVI  TABLE    OF    CONTENTS. 

CHAPTER    VI.  Page 

Important  Medicinal  Agents  in  Gastric  Therapy,  .    .    .     316-335 

Hydrochloric  Acid. — The  Alkalies. — The  Bitter  Tonics  and  So-called 
Stomachic  Remedies. — Digestive  P'erments. 

CHAPTER  Vn. 
Surgical  Treatment  of  Organic  Gastric  Diseases,  .    .    .     336-357 

Various  Forms  of  Operations  practised  upon  the  Stomach. — The  Fun- 
damental Factors  Influencing  the  Rate  of  Mortality  in  Gastric  Opera- 
tions.— Operative  Statistics. 

CHAPTER  VHI. 
Influence  of  G.-vstric  Diseases  upon  Other  Organs  and 

ON  Metabolism, 358-375 

The  Influence  of  Diseases  of  Other  Organs  on  the  Stomach. 

CHAPTER  IX. 
The  Blood  and  Urine  in  Stoimach  Diseases,     .....     376-3S8 

The  Gases  of  the  Stomach. 


PART    THIRD. 


THE  GASTRIC  CLINIC. 


CHAPTER  I. 
Acute  Gastritis, 389-419 

Simple  Acute  Gastritis. — Phlegmonous  or  Purulent  Gastritis. — Suppur- 
ative Inflammation  of  the  Gastric  Mucosa. — Abscess  of  the  Stomach. 
— Infectious  Gastritis. — Gastritis  Mycotica  or  Parasitaria. — Gastritis 
Diphtherica  and  Crouposa. — Toxic  Gastritis. — Gastritis  Venenata. 

CHAPTER  II. 
Chronic  Gastritis, 420-461 

Literature. 

CHAPTER  III. 
Ulcer  of  the   Stomach, 462-491 

Ulcus  Ventriculi,  Pepticum,  Rotundum,  Perforans,  Rodens,  Corro- 
sivum,  e  Digestione. — Literature. 

CHAPTER   IV. 
Malignant  Tumors  of  the  Stomach, 492-548 

Carcinomata. — Sarcomata. — Literature. — Table  of  Differential  Diag- 
nostic Points. 


TABLE    OF    CONTENTS.  Xvii 

CHAPTER  V.  Page 

Stomach  Diseases  Caused  by  Infectious  Granulomata,  .     549-564 

Tuberculosis  of  the  Stomach. — Syphihs  of  the  Stomach. — Literature. 

CHAPTER  VI. 
Benign  Tumors  of  the  Stomach, 565-572 

Myomata. — Fibromata.  — Liporaata.— Polypi.  —  Myxomata. — Papillo- 
mata. — Lymphadenomata. — Pedunculate  Tumors. — Foreign  Bodies. — 
Gastroliths. 

CHAPTER  VII. 
Motor  Insufficiency, 573-602 

Gastric  Atony  or  Myasthenia. — Gastrectasia  (Dilatation  of  the 
Stomach) . — Literature. 

CHAPTER  yni. 

Enteroptosis — Gastroptosis,   .    , '  .     603-629 

Literature. 

CHAPTER  IX. 
Neuroses  of  the  Stomach, 630-687 

General  Considerations.  —  Cardiospasm.  —  Pyloric  Spasm.— Gastro- 
spasm. — Gastric  Hyperperistalsis. — Nervous  Eructation.  —  Nervous, 
Habitual,  or  Reflex  Vomiting.  —  Insufficiency  or  Incontinence  of  the 
Cardia. — Rumination  or  Merycism. — Insufficiency  or  Incontinence  of 
the  Pylorus. — Atony  of  the  Stomach. — Literature. 

CHAPTER  X. 
Sensory  Neuroses, 688-710 

Hyperesthesia. — Gastralgia. — Bulimia,  or  Hyperorexia. — Acoria. — 
Nervous  Anorexia. 

CHAPTER  XI. 

Neuroses  of    Secretion,  711-742 

Hyperchylia. — Periodic  Atypical  Flow  of  Gastric  Juice. — Chronic  Con- 
tinuous Flow  of  Gastric  Juice. — Literature. — Subacidity. 

CHAPTER  XII. 
Achylia  Gastrica, =    .    .    .     743-757 

CHAPTER  XIII. 
Nervous    Dyspepsia    (Leube). — Neurasthenia     Gastrica 

(Ewald),      758-769 

Heterochylia. 


Diseases  of  the  Stomach. 


PART    FIRST. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  DIGESTIVE 

ORGANS.— METHODS  AND  TECHNICS 

OF  DIAGNOSIS. 


CHAPTER  I. 

ANATOMY  OF  THE  STOMACH. 

Many  valuable  contributions  to  the  subject  of  the  macroscopical 
and  microscopical  anatomy  of  the  stomach  have  been  made  during 
recent  years.  In  the  subjoined  brief  synopsis  we  have  availed 
ourselves  of  the  valuable  researches  of  F.  Mall,  and  of  the  works 
quoted  by  him  in  the  bibliography  given  in  his  article  in  the  "  Johns 
Hopkins  Hospital  Reports,"  volume  i.  The  comprehensive  works 
of  Oppel,  Spalteholz,  and  others  which  have  appeared  during 
1896-97,  have  also  been  consulted. 

The  stomach  is  the  dilated,  sac-like  portion  of  the  digestive 
tract,  between  the  esophagus  and  the  small  intestine.  One  can 
distinguish  a  lower  convex  arch,  the  greater  curvature,  which  is 
directed  toward  the  left  and  downward ;  and  an  upper  concave 
arch,  the  lesser  curvature,  which  is  directed  toward  the  right  and 
upward.  The  broad  left  end  of  the  greater  curvature  is  called  the 
fundus,  the  size  of  which  varies  according  to  age.  Between  the 
fundus  and  the  lesser  curvature  is  situated  the  cardia,  being  the 
continuation  and  funnel-shaped  expansion  of  the  esophagus. 
While  it  is  not  marked  on  the  outside  of  the  organ,  there  is  a 
distinct  limiting  line  internally  on  the  mucous  membrane,  which  is 
caused  by  a  change  in  the  structure  of  the  epithelial  lining.  This 
zigzag  line  separates  the  cardia  from  the  esophagus.     It  is  now 

17 


1 8  ANATOMY    OF    THE    STOMACH. 

well  known  that  at  this  point  the  arrangement  of  the  muscular 
fibers  and  veins  is  also  different  from  that  in  the  esophagus. 

The  location  of  the  cardia  in  the  adult  is  at  the  twelfth  dorsal 
vertebra.  At  about  the  height  of  the  bifurcation  of  the  bronchi, 
the  spiral  curving  of  the  esophagus  around  the  aorta  begins.  By 
executing  this  curve,  the  convexity  of  which  is  toward  the  I'ight, 
the  esophagus  gets  to  the  left  side  of  the  aorta,  and  passes 
through  the  diaphragm  in  the  foramen  oesophageum,  near  the 
spinal  column. 

The  stomach  becomes  narrower  from  the  fundus  toward  the 
pylorus.  Near  the  pylorus  there  is  a  constriction,  caused  by  a 
ring-like  formation  of  muscular  tissue,  which  corresponds  to  the 
pyloric  valve.  The  muscular  tissue  is  covered  internally  by  the 
gastric  mucous  membrane,  the  latter  forming  the  pyloric  valve ; 
the  opening  of  this  valve  is  of  varying  diameter.  The  part  of  the 
stomach  in  advance  of  the  pylorus  is  called  the  antrum  pyloricum, 
and  is  frequently  separated  from  the  greater  curvature  by  an 
indentation  or  depression.  This  antrum  may  be  elongated  so  as 
to  assume  resemblance  to  the  intestine;  which  is  frequently  the  case 
in  the  female. 

On  the  anterior  and  posterior  walls  of  the  stomach,  running 
along  between  the  muscular  and  serous  coats  of  the  organ,  are  two 
band-like  stripes,  consisting  of  elastic,  smooth,  muscular  fibers. 
These  are  the  pyloric  ligaments. 

The  size  of  the  stomach  depends  upon  age,  sex,  and  individuality, 
and  upon  the  degree  of  its  distention.  The  long  axis  extends 
from  25  to  35  cm.  The  greatest  vertical  measurement,  at  the  cardia, 
is  15  cm.,  and  the  greatest  straight  diameter  is  from  11  to  12  cm.; 
the  smallest,  at  the  antrum  pyloricum,  is  from  three  to  four  cm. 
In  the  female  it  is  generally  smaller  and  more  slender. 

The  capacity  varies  considerably ;  Ewald  considers  that  from 
1600  to  1700  c.c.  is  the  normal  limit.  Three-fourths  of  the  stomach 
belong  to  the  left  half  of  the  body  and  one-fourth  belongs  to  the  right 
half  The  cardia  is  located  behind  the  median  edges  of  the  fifth  and 
sixth  ribs.  The  fundus,  the  largest  part  of  the  body  of  the  organ,  is 
in  the  left  hypochondrium ;  the  rest,  with  the  pyloric  part,  is  in 
the  epigastrium.  The  pylorus  lies  in  the  right  half  of  the  body,  but 
occasionally  changes  to  the  middle  line  at  the  level  of  the  seventh 
and  eighth  ribs,  in  a  line  with  the  ensiform  cartilage.  The  lesser 
curvature  runs  along  to  the  left,  and  near  the  spinal  column.     The 


DIAPHRAGM PANCREAS.  I9 

vaulting  dome  of  the  fundus,  which  applies  itself  to  the  concavity 
of  the  diaphragm,  is  the  highest  point.  The  deepest  point  of  the 
stomach  is  in  the  greater  curvature,  in  the  inferior  half  of  an  imagi- 
nary straight  line  connecting  the  ensiform  cartilage  with  the  umbili- 
cus. Both  the  highest  and  lowest  parts  of  the  stomach  are  moved 
about  according  to  the  level  of  the  diaphragm  and  the  distention  of 
the  stomach.  In  an  empty  condition,  the  stomach  is  withdrawn  into 
the  upper  portion  of  the  abdomen  ;  but  when  filled  it  extends  in 
all  directions,  but  mostly  in  the  direction  of  its  long  axis,  from  the 
left  above  downward  to  the  right.  In  a  state  of  moderate  distention 
about  40  cm.  of  its  anterior  wall  comes  in  contact  with  the  inner 
surface  of  the  anterior  abdominal  wall. 

The  diaphragm  covers  the  fundus  and  the  largest  part  of  the 
left  segment,  while  the  left  lobe  of  the  liver,  up  to  the  sulcus  inter- 
lobularis,  covers  the  smallest  part;  that  is,  the  lesser  curvature 
and  the  pyloric  portion.  From  this  fact  arises  the  difficulty  in 
palpating  tumors  in  the  latter  place,  which  is  impossible,  except  when 
gastroptosis,  or  descent  of  the  stomach,  moves  it  away  from  the 
liver.  In  the  state  of  expansion  or  dilation,  the  stomach  moves 
out  from  behind  the  liver;  but  the  lesser  curvature  can  not  change 
its  location  to  any  considerable  extent,  and  the  change  of  location 
of  the  whole  stomach  caused  by  filling  is  produced  almost  exclu- 
sively by  an  extension  of  the  greater  curvature. 

The  pancreas  extends  along  the  posterior  wall  of  the  stomach. 
At  the  upper  edge  of  the  pancreas  are  the  splenic  artery  and  vein. 
The  transverse  colon  runs  along  the  greater  curvature,  and  its  left 
flexure  fills  the  remaining  space  in  the  left  hypochondrium.  The 
location  of  the  stomach  is  fixed  by  a  ligamentous  attachment  of  the 
cardia,  by  the  pylorus,  and  also  by  a  number  of  suspensory  liga- 
ments, which  are  all  formations  of  the  peritoneum.  Some  authors 
say  that  the  stomach  is  supported  in  this  position  by  intra- 
abdominal pressure.  The  experiments  of  Moritz  (of  Munich)  and 
the  author  have  proved  that  intra-abdominal  pressure  adds  nothing 
to  the  support  of  the  stomach.  The  gastrophrenic  ligament,  which 
toward  the  right  passes  into  the  lesser  omentum,  and  toward  the 
left  extends  into  the  phrenosplenic  ligament,  surrounds  and  em- 
braces the  cardia,  which  is  lower  than  the  fundus,  its  situation 
corresponding  to  the  upper  end  of  the  sixth  and  seventh  costal 
cartilages,  or  to  the  level  of  the  ninth  thoracic  vertebra.  This  part 
of  the  stomach  is  therefore  moved  to  the  left  of  the  middle  line, 


20  ANATOMY  OF  THE  STOMACH. 

and  next  to  the  spinal  column,  at  about  the  level  of  the  twelfth 
thoracic  and  first  lumbar  vertebrae;  here  it  is  fixed  to  the  lumbar 
part  of  the  diaphragm. 

The  greater  omentum  arises  from  the  large  curvature.  The 
posterior  fold  of  this  omentum  forms  the  mesocolon  transversum. 
This  is  the  reason  why  changes  of  location  in  the  greater  omentum 
(hernia  and  inflammatory  adhesions)  can  produce  traction  upon  the 
stomach.  As  the  stomach  is  really  attached  only  at  the  cardia, 
and  the  pylorus  adheres  to  the  posterior  abdominal  wall  by  the 
descending  portion  of  the  duodenum,  the  organ  is  capable  of  being 
moved  about,  not  so  much  in  its  entirety  as  in  its  parts  (the  great 
curvature,  for  instance).  The  stomach  has  a  complete  peritoneal 
covering,  which  consists  of  an  anterior  and  posterior  layer,  uniting 
at  the  two  curvatures  of  the  stomach  to  form  the  lesser  and  greater 
omentum ;  between  these  two  layers  a  space  is  left  for  the  blood- 
and  lymph-vessels  of  the  stomach. 

Muscular  Layer. — The  muscular  stratum  contains  three  kinds 
of  fibers, — longitudinal,  transverse,  and  oblique.  The  longitudinal 
layer  of  muscular  fibers,  a  continuation  of  those  of  the  esophagus, 
presents  a  denser  arrangement  at  the  lesser  curvature  than  at  the 
greater,  and  forms  the  ligamenta  pylorica  at  the  pyloric  part,  which 
are  bands  of  muscular  fibers  expanded  and  broadened  out, — not 
ligaments  in  the  real  sense  of  the  word. 

The  circular  layer  of  muscular  fibers  is  placed  internally  to  the 
longitudinal  layer,  the  fibers  of  which  it  crosses  at  right  angles. 
The  fibers  of  this  circular  layer  are  placed  around  the  stomach  in 
a  ring  or  belt-like  manner ;  at  the  pylorus  it  shows  a  local  thicken- 
ing of  the  muscle  rings — the  sphincter  pylori ;  a  fold  of  the  mucosa 
to  the  innermost  side  of  this  sphincter  constitutes  the  pyloric  valve. 
The  longitudinal  fibers  also  have  a  part  in  the  formation  of  the 
sphincter,  for  while  the  superficial  layer  of  longitudinal  fiber 
passes  on  over  the  pyloric  sphincter  into  the  duodenum,  the  deeper 
longitudinal  fibers  enter  the  pyloric  valve  encircling  and  grasping 
the  circular  fibers  in  a  loop-like  manner  (dilator  pylori — Riidinger), 
The  cardia  has  no  special  sphincter,  but  the  oblique  fibers  cross 
and  decussate  at  the  periphery  of  this  portion.  The  sphincter 
pylori  is  contracted  during  digestion,  but  gas  and  liquids  can 
readily  escape  through  the  cardia.  The  oblique  fibers  are  limited 
chiefly  to  the  cardiac  end  of  the  stomach,  where  they  are  disposed 
as  a  thick,  uniform  layer,  some  passing  obliquely  from  left  to  right. 


MUCOUS    MEMBRANE.  21 

others  from  right  to  left,  around  the  cardiac  orifice.  The  sub- 
mucosa,  or  cellular  coat  of  the  stomach,  consists  of  a  loose,  fila- 
mentous, areolar  tissue,  and  loosely  binds  the  mucosa  to  the 
muscular  layers. 

The  most  important  and  interesting  layer  is  the  mucosa,  or 
mucous  membrane  proper,  of  the  stomach ;  it  is  a  thick  layer  with 
a  smooth,  soft,  velvety  surface.  During  infancy,  and  immediately 
after  death,  it  is  of  a  pinkish  tinge,  but  in  adult  life  and  in  old  age  it 
becomes  of  a  pale  straw  or  ash-gray  color ;  at  the  pylorus  it  is 
much  thicker  than  at  the  cardia.  During  the  contracted  state  of 
the  organ  it  is  thrown  into  numerous  plaits  or  rugae,  which,  for  the 
most  part,  have  a  longitudinal  direction,  and  are  most  marked 
toward  the  lesser  end  of  the  stomach  and  along  the  greater  curva- 
ture; these  folds  are  entirely  obliterated  when  the  organ  becomes 
distended. 

Structure  of  the  Mucous  Membrane. — When  examined  with 
a  lens,  the  inner  surface  of  the  mucous  membrane  presents  a  pecu- 
liar honeycomb  appearance,  from  being  covered  with  small,  shallow 
depressions,  or  alveoli,  of  a  polygonal  or  hexagonal  form,  which 
vary  from  y^  to  -^^  of  an  inch  in  diameter,  and  are  separated  by 
slightly  elevated  ridges.  In  the  bottom  of  the  alveoli  are  seen  the 
orifices  of  minute  tubes,  the  gastric  follicles,  which  are  situated 
perpendicularly  side  by  side  in  the  entire  substance  of  the  mucous 
membrane ;  they  are  short,  and  of  a  simple  tubular  character 
toward  the  cardia,  but  at  the  pyloric  end  they  are  longer,  more 
thickly  set,  convoluted,  and  terminate  in  dilated  saccular  ex- 
tremities, or  are  subdivided  into  from  two  to  sixteen  tubular 
branches. 

Watney  has  pointed  out  that  these  convoluted,  or  coiled,  tubes 
form  the  transition  from  the  simple  tubular  follicles  to  the  convo- 
luted glands  of  Brunner,  which  lie  immediately  below  the  pylorus. 
The  gastric  follicles  are  composed  of  a  homogeneous  basement 
membrane,  formed  by  the  connective  tissue  framework,  lined  upon 
its  free  surface  by  a  layer  of  cells,  which  differ  in  their  character 
in  different  parts  of  the  stomach.  Toward  the  pylorus  these  tubes 
are  lined  throughout  by  columnar  or  cuboidal  epithelium  ;  they 
are  termed  the  mucous  glands,  and  are  supposed  to  secrete  the 
gastric  mucus.  In  other  parts  of  the  organ  the  deep  part  of  each 
tube  is  filled  with  nucleated  cells,  the  upper  fourth  of  the  tube 


22  AXATOMV  OF  THE  STOMACH. 

being  lined  by  columnar  epithelium:  These  are  called  the  peptic 
glands,  and   are   the   supposed   source  of  the  gastric  juice. 

Simple  follicles  are  found  in  greater  or  less  numbers  over  the  en- 
tire surface  of  the  mucous  membrane  ;  they  are  most  numerous 
near  the  pyloric  end  of  the  stomach,  and  are  especially  distinct  in 
early  life.  The  epithelium  lining — the  mucous  membrane  of  the 
stomach  and  its  alveoli — is  of  the  columnar  variety. 

Usually  four  to  sixteen  gland  openings  are  found  at  the  base  of 
each  follicle.  According  to  Sappey  there  are  5,000,000  of  these 
glands  in  the  organ,  for  which  reason  the  gastric  mucosa  may 
justly  be  considered  a  continuous  gland  spread  out  into  a  flat 
surface  (Hyrtl  and  Luschka).  The  gland  tubules  are  as  long 
as  the  entire  thickness  of  the  mucosa,  and  their  sac-like  and 
branched  bases  extend  into  the  muscularis  mucosa,  the  action  of 
these  muscular  fibers  assisting  in  the  evacuation  of  the  tubules 
during  digestion.  The  ends  of  the  tubules  extending  into  the 
muscular  layer  are  usually  branched. 

The  cylindrical  epithelium  of  the  surface  of  the  stomach,  -which 
is  separated  from  the  pavement  epithelial  lining  of  the  esophagus 
by  a  distinct  but  irregular  line  at  the  beginning  of  the  cardia,  is 
found  also  in  the  beginning  of  the  tubules,  but  only  extends  down- 
ward to  one-quarter  or  one-third  their  length  ;  from  this  point 
downward  they  are  no  longer  observed,  but  two  different  kinds  of 
cells  are  now  seen  to  line  the  glandular  tubule.  One  variety 
of  lining  cells  is  located  toward  the  axis  of  the  tube,  and  is 
known  as  the  adelomorphous  cells  of  Rollet,  because  they 
show  no  cell  contours  or  outline  in  the  fresh  state,  called  by 
Heidenhain  chief  cells  ;  the\'  have  a  cubical,  cylindrical  form  and 
indistinct  nuclei.  The  second  variety  shows  larger,  round  cells,  the 
delomorphous  cells  of  Rollet,  also  known  as  parietal  cells,  which  in 
the  fresh  state  exhibit  a  finely  granular  contour,  becoming  sharply 
outlined  on  addition  of  water  or  salt-solution  ;  they  show  coarsely 
grained  contents  and  a  distinct  nucleus.  The  first  form,  the  cubical 
or  cylindrical,  chief,  central,  or  adelomorphous  cells,  are  supposed 
to  secrete  the  ferments,  pepsin  and  rennin  ;  the  second  form,  the 
larger,  round,  delomorphous,  oxyntic,  or  parietal  cells,  are  sup- 
posed to  secrete  the  HCl. 

The  peptic  glands  consist  of  a  duct,  a  neck,  and  a  fundus;  the 
latter  is  the  deepest  portion,  and  is  often  divided.  These  tubular 
glands  apparently  have  a  distinct   membrana   propria   separating 


PEPTIC    CELLS.  23 

them  from  the  loose,  areolar,  connective  tissue,  in  which  they  lie. 
Mall  has  not  been  able  to  establish  the  existence  of  a  distinct  base- 
ment membrane. 

Three  Kinds  of  Cells  of  the  Peptic  Glands. — First,  the  cylin- 
drical cells  of  the  gland  duct  and  pit,  lining  one-fourth  to  one-third 
of  the  distance  from  the  surface  of  the  mucous  membrane  downward. 
They  are  a  continuation  of  the  cylindrical  epithelium  of  the  general 
internal  surface  of  the  gastric  mucous  membrane ;  these  cells  seem 
to  secrete  mucus  only.  Secondly,  the  lightly  colored,  pyramidal  or 
cuboidal  cells,  with  a  granular  protoplasm  and  spherical  nucleus. 
These  cells  do  not  stain  with  anilin,  and  were  termed  adelomor- 
phous cells  by  Rollet  because  they  show  no  cell  contours  in  the 
fresh  state.  Rosenheim  states  that  they  are  almost  clear  and  trans- 
parent during  fasting,  and  become  cloudy  and  granular  during 
digestion.  Heidenhain  designated  them  as  the  chief,  or  central, 
cells,  and  they  were  held  by  him  to  be  the  sources  of  the  ferments, 
— pepsinogen  and  rennin  zymogen.  These  chief,  or  central,  cells 
touch  the  lumen  of  the  duct  more  extensively  than  the  next  follow- 
ing variety.  The  third  kind  of  peptic  cells  are  known  as  the  bor- 
der, parietal,  or  oxyntic  cells,  because  they  rest  upon  the  membrana 
propria  with  much  broader  bases  than  the  chief,  or  central,  cells. 
For  this  very  reason  they  participate  to  a  less  degree  in  the  limita- 
tion of  the  lumen  of  the  duct.  They  are  generally  round  or  tri- 
angular, finely  granular,  and  stain  intensely  with  anilin,  and  were 
designated  by  Rollet  as  delomorphous  cells.  Heidenhain  supposes 
them  to  be  the  sources  of  hydrochloric  acid.  If  we  assume,  for  the 
sake  of  locating  these  various  cells,  a  division  of  the  tubule  into 
four  sections,  beginning  at  the  portion  nearest  the  submucosa,  we 
shall  have  (a)  the  fundus  of  the  gland  tubule;  then  (d)  the  outer 
secretory  portion  ;  (c)  the  inner  secretory  portion  ;  and,  opening  on 
the  inner  surface  of  the  mucosa,  (<^)  the  alveolus  ("  Vorraum  "). 
Then,  one  finds  the  border,  parietal,  oxyntic,  delomorphous,  or 
anilin,  cells  most  numerous  in  the  outer  secreting  portion,  and 
becoming  scarce  in  the  fundus  or  end  portion.  A  fourth  kind  of 
cell  occurring  at  rare  intervals  is  known  as  Nussbaum's  cell — its 
significance  is  unknown. 

Heidenhain  asserted  that  there  were  no  border  cells  in  the 
fundus  at  all;  but  this  has  been  denied  by  Stohr,  Kupffer,  and  Boas. 
The  size  of  border,  or  acid,  cells  depends  upon  the  stage  of  diges- 
tion ;    as    this    function  proceeds,  the    border    cells  increase,  and 


24  ANATOMY  OF  THE  STOMACH. 

diminish  again  at  the  end  of  digestion.  The  chief,  central,  or 
ferment,  cells  enlarge  also,  and  become  darker  during  digestion. 
In  a  fasting  state,  the  chief  cells  are  largely  in  excess.  Heiden- 
hain's  conclusions,  that  the  chief,  or  central,  cells  are  producers  of 
the  digestive  ferments,  and  that  the  border,  or  anilin-staining,  cells 
produce  the  hydrochloric  acid,  have  been  confirmed  by  a  number  of 
other  observers  (Griitzner,  von  Swiezicki,  and,  recently,  Sehrwald 
and  Mall). 

Their  method  of  experimentation  was  mainly  the  following :  It 
is  known  that  the  glandular  tubules  of  the  pyloric  region  contain 
only  chief,  or  central,  cells  (producing  ferments  only,  and  no  acid), 
while  the  gland  tubules  of  the  fundus  contain  both  central  cells 
and  also  border,  or  acid,  cells.  Now,  Heidenhain  succeeded,  in  a 
number  of  dogs,  in  removing  the  pyloric  portion  of  the  stomach 
entirely,  and  uniting  the  organ  with  the  external  abdominal  wall. 
In  other  dogs  he  removed  the  fundus  entirely,  leaving  the  pyloric 
portion  intact,  and  succeeded  in  making  this  altered  stomach  with- 
out a  fundus  unite  with  the  external  abdominal  wall. 

He  therefore  had  two  kinds  of  operated  animals  with  stomachs 
opening  on  the  abdomen.  After  this,  it  was  found  that  animals  in 
which  the  pyloric  region  was  excised  furnished  a  juice  that  con- 
tained both  acid  and  pepsin  ;  these  are  therefore  produced  by  the 
glands  of  the  fundus  which  contain  both  varieties  of  secretory  cells. 
In  the  animals,  however,  that  had  been  deprived  of  the  fundus 
by  excision,  the  only  secretory  surface  that  was  left  being  the 
pyloric  region,  it  was  found  that  an  alkaline  juice  was  secreted  con- 
taining only  ferments.  That  this  juice  did  contain  pepsin  was 
proved  by  its  power  of  digesting  fibrin  when  hydrochloric  acid 
was  added  to  it. 

Now,  as  the  gland  tubules  of  the  pylorus  contain  only  chief,  or 
central,  cells,  which  do  not  stain  with  anilin,  the  conclusion  is  justi- 
fiable, that  the  chief  cells  secrete  only  ferments,  and  that  therefore 
the  border,  or  anilin-staining,  cells  must  secrete  the  hydrochloric 
acid. 

It  has  been  found  that  the  border,  or  acid,  cells, — called  also  the 
oxyntic  cells, — are  in  communication  with  the  central  canal  of 
the  gland  tubule  by  a  tiny  canaliculus, — an  extension  from  the 
central  lumen  of  the  gland  to,  or  into,  the  oxyntic,  or  acid,  cells. 
These  canaliculi  were  brought  out  with  the  silver  stain  bv  Golgi. 


CHAPTER  II. 

HISTOLOGY  OF  THE  STOMACH. 

R.  R.  Bensley,  b.a.,  m.b.,  has  published  a  ven-  interesting  paper 
on  the  "  Histology  and  Physiology  of  the  Gastric  Glands,"  in  the 
"Proceedings  of  the  Canadian  Institute,  1896."  The  work  was 
done  in  the  biological  laboratory  of  the  University  of  Toronto. 
Mr.  Bensley  was  kind  enough  to  present  us  with  four  sketches 
illustrating  the  various  phases  of  secretion  in  the  gland  cells  of 
the  deep  ends  of  the  fundus  glands  of  the  cat's  stomach.  We 
consider  his  results  a  valuable  addition  to  the  work  of  Heiden- 
hain,  Ebstein,  Langley,  Sewall,  and  others.  With  staining  as  used 
by  him,  it  is  possible  to  recognize  the  precursory  stages  of  the  fer- 
ments within  the  structure  of  the  cells.  We  submit  Mr.  Bensley's 
drawings,  with  explanatory  text.    The  following  are  his  conclusions  : 

"  I.  During  digestion,  a  substance  similar  in  chemical  properties 
to  the  chromatin  of  the  nucleus  makes  its  appearance  in  the  outer 
clear  zone  of  the  chief  cells  of  the  fundus  glands.  This  substance, 
which  may  be  called  prozymogen,  stains  deeply  and  readily  in 
hematoxylin,  and  presents  a  characteristic  fibrillated  appearance. 
During  rest  this  prozymogen  is  used  up  in  some  way,  giving  rise 
to  zymogen  granules. 

"  2.  The  chief  cells  of  the  neck  of  the  gland  do  not  contain  at 
any  period  of  digestion  either  zymogen  or  prozymogen,  but  are 
engaged  in  the  formation  of  a  mucinoid  secretion,  which  has  a 
powerful  elective  affinity  for  indulin  and  Bordeaux  red,  and  stains 
metachromatically  in  thionin. 

"  3.  The  pyloric  gland  cells,  likewise,  form  neither  zymogen  nor 
prozymogen,  and  are  similar  in  structure,  in  staining  properties, 
and  in  the  nature  of  their  secretion,  to  the  cells  of  the  neck  of  the 
fundus  gland. 

"  4.  The  cells  of  the  pyloric  glands  and  of  the  neck  of  the 
fundus  gland  pass,  by  gradual  transition,  into  the  mucous  cells  of 
the  surface,  to  which  they  are  obviously  closely  allied." 

From  Mall's  article  on  the  anatomy  of  the  stomach  ("  Johns  Hop- 

25 


26 


HISTOLOGY    OF    THE    STOMACH. 


kins    Hospital   Reports,"    vol.    i)   we  have  inserted  the  following 
graphic  description  : 

"Mucosa. — That  more  than  one  kind  of  gland  is  present  in  the 


^4^ 


^ 


B     b 


Fig.  2. 


x 


Fig.  3. 

Sections  of  Deep  Ends  of  Fundus  Glands  of  the  Cat  in  Different  Secretive  Phases. 

X    1000. — {Bensley.) 

Fig.  I. — From  a  fasting  stomach.  The  chief  cells  are  filled  with  large  zymogen  granules;  nuclei  near 
the  outer  ends  of  cells.     Gentian-violet  preparation,     b.  Border  cells. 

Fig.  2. — Six  hours  after  an  abundant  meal  of  raw  flesh.  The  chief  cells  exhibit  two  zones,  the  inner 
occupied  by  large  zymogen  granules,  the  outer  by  a  deeply  staining,  obscurely  fibrillar  element,  pro- 
zymogen;  the  nuclei  lie  at  the  junction  of  the  two  zones,  b.  Border  cells  pr.  Prozymogen.  c.  Mucin 
secreting  cell,  similar  to  those  found  in  the  neck  of  the  gland.     Gentian-violet  preparation. 

Fig.  3. — Twelve  hours  after  feeding  with  sponge  soaked  in  fat.  Preparation  stained  in  hematoxylin 
exhibits  a  deeply  stained  outer  zone  filled  with  prozymogen,  and  a  clear  inner  zone  from  which  the 
granules  have  disappeared  in  course  of  preparation.  The  nuclei  are  now  much  nearer  to  the  lumen. 
b.  Border  cells,    pr.  Prozymogen. 

Stomach  has  been  repeatedly  noticed  (Wassman,  Frerichs,  Brinton, 
Leydig,  Kolliker),  but  a  more  careful  study  of  them  was  delayed 
until  1870  (Heidenhain,  Rollet). 


MUCOSA.  27 

"  In  general  there  are  two  kinds  of  glands  present  in  the  dog's 
stomach, — the  pyloric  and  the  peptic.  The  peptic,  in  turn,  are 
formed  in  great  part  of  two  kinds  of  cells, — the  border  and  the 
central. 

"  The  section  through  the  entire  length  of  the  stomach  shows 
that  in  the  pyloric  region  the  necks  of  the  glands  are  the  longest 
(.68  mm.),  and  that  they  diminish  in  length  throughout  the  middle 
zone  (.25  mm.),  until  the  cardiac  portion  is  reached.  In  the  pyloric 
portion,  where  the  necks  of  the  glands  are  the  longest,  many  gland 
tubes  empty  into  one  outlet;  in  the  middle  zone  there  are  less,  in 
rough  about  nine,  into  each  gland  mouth  ;  while  in  the  cardiac  por- 
tion each  gland  has  a  special  opening — in  other  words,  there  are  no 
gland  necks.  In  the  pyloric  portion  the  glands  are  composed 
wholly  of  central  cells.  In  the  central  zone  there  are  many  border 
cells,  the  proportion  to  the  central  cells  being  as  described  by 
Heidenhain  and  his  pupils.  Throughout  the  fundus  are  but  few 
border  cells,  w^hile  around  the  esophagus  there  is  a  small  zone  in 
which  there  are  many  border  cells. 

"  In  the  pyloric  portion  about  1600  gland  tubes  open  within  each 
square  centimeter  of  mucous  membrane,  in  the  middle  zone  2500, 
and  in  the  fundus  4900.  For  an  average  stomach  there  are  about 
28  square  cm.  area  in  the  pylorus,  108  in  the  middle  zone,  and  120 
in  the  cardiac  portion,  or  these  surfaces  are  to  each  other  as  7  :  27  : 
30.  The  estimation  carried  farther  gives  somewhat  over  1,000,000 
gland  openings  in  the  stomach.  On  the  other  hand,  if  the  blind 
tubes  opposite  the  muscularis  mucosa  are  estimated,  the  number 
exceeds  16,500,000.  In  other  words,  each  gland  neck  subdivides 
16  times,  on  an  average,  before  the  muscularis  mucosa  is  reached. 
It  may  be  interesting  to  note  that  for  each  gland  opening  in  the 
stomach  we  have  one  villus  in  the  intestine,  and  for  each  sub- 
division there  is  one  Lieberkiihn's  crypt." 

Mall's  observation,  as  well  as  that  of  others,  does  not  confirm 
Heidenhain's  statement,  i.  e.,  that  "  wherever  we  have  central  cells 
we  have  pepsin."  Yet,  it  seems  true,  that  the  degree  of  acidity  is  in 
proportion  to  the  number  of  border  cells  present  in  any  portion  of 
the  stomach,  and  that  there  are  portions  of  the  stomach  which  do 
not  contain  border  cells,  but  yield  pepsin.  In  general,  the  forma- 
tion of  pepsin  is  most  marked  in  those  portions  of  the  stomach 
which  produce  most  acid;  and  this  ought  to  be  the  case,  for  acid 
favors    the    formation    of  pepsin  from   pepsinogen   (Podwyssozki, 


28  HISTOLOGY    OF   THE    STOMACH. 

Langley,  and  Edkins),  and  the  pepsin  seems  more  or  less  combined 
with  acid  (Schiff,  Richet).  We  must,  therefore,  conclude  with 
Heidenhain,  that  the  border  cells  play  a  most  important  part  in  the 
formation  of  acid.  Between  the  glands  lie  the  blood-vessels,  lym- 
phatics, some  round  cells,  and  the  reticulum.  In  those  portions  of 
the  stomach  in  which  there  is  a  '  neck  zone,'  there  is  a  distinct 
layer  of  reticulum  fibrils.  In  this  layer  peculiar  spindle  cells  are 
frequently  seen  which  surround  the  gland  openings  and  appear 
much  like  the  subepithelial  cells  in  the  villi  of  the  intestine.  Under 
no  condition  could  a  basement  membrane  be  isolated,  nor  does 
Mall  believe  it  exists,  but  instead  there  is  a  most  beautiful  network 
of  the  reticulum. 

"  Conclusions. — From  a  histological  standpoint  the  mucous 
membrane  of  the  stomach  may  be  divided  into  three  zones — the 
pyloric,  with  no  border  cells  ;  the  middle,  with  many  border  cells ; 
and  the  fundus,  with  but  few  border  cells. 

"  Digestion  of  the  different  portions  of  the  mucous  membrane  with 
weak  HCl  shows  that  the  middle  zone  digests  most  easily,  the 
fundus  less  quickly,  and  the  pyloric,  as  a  rule,  not  at  all.  Assum- 
ing that  the  rapidity  of  digestion  of  the  different  portions  is  in 
proportion  to  the  quantity  of  pepsin  present,  it  makes  it  probable 
that  most  pepsin  is  formed  in  the  middle  zone.  Although  it  has 
been  proved  that  pepsin  is  formed  in  glands  which  do  not  contain 
border  cells,  in  general  it  may  be  stated  that  the  amount  of  pepsin 
formed  by  the  different  glands  is  in  proportion  to  the  number  of 
border  cells. 

"The  degree  of  acidity  of  the  mucous  membrane  is  in  proportion 
to  the  number  of  border  cells  present.  It  is  reasonable  to  suppose 
that  the  formation  of  acid  in  any  portion  of  the  stomach  aids 
materially  in  the  formation  of  pepsin  in  the  same  part.  This  is 
very  essential,  because  acid  favors  the  formation  of  pepsin  from 
pepsinogen.  Since  border  cells  are  only  with  the  greatest  diffi- 
culty digested  in  acid,  we  can  not  ascribe  to  them  the  power  to 
secrete  pepsin  ;  and  since  the  morphology  of  the  central  cells  varies 
during  digestion  and  rest,  and  they  are  also  easily  digested  upon  the 
addition  of  acid,  we  must  conclude  with  Heidenhain  that  the  former 
are  probably  concerned  in  the  production  of  acid  and  the  latter  in 
the  production  of  pepsin. 

"  When  the  stomach  is  forcibly  distended  it  is  found  that  the  dila- 
tation is  mostly  at  the  expense  of  the  fundus.     This  seems  also  to 


PLATE  1. 


Three  Sections  of  Stomach-walls  Placed  Side  by  Side  to  Show  the  Positions 

OF  Blood-vessels  and  Lymphatics  to  the  Different  Layers. 
M,  Mucosa.     M' ,   Muscularis  mucosse.      .5",   Submucosa.      C  and  Z,  Circular  and  longitudinal 
muscles  enlarged  70  times. 


u      ^    -^ 


b    t*  o  o 

—        p      1)      M 


<    -S.-  -5 


c/2 

S 

.2 

<; 

■  ' 

.— 

T) 

c 

n 

so 

(U 

CS 

S 

z 

,jr 

? 

CJ 

o 

c 

rt 

H 

(U 

■  ^ 

•Ji 

O 

n 

^ 

.^ 

•^ 

o 

M 
^ 

V 

c 

a 
o 

O 

i> 

o 

"3 

S 

P<    6    S 


_3    ^ 


MUCOSA.  29 

be  the  case  when  the  stomach  is  naturally  filled  with  food. 
Although  the  middle  zone  is  practically  not  stretched  when  the 
stomach  is  filled,  distention  seems  to  favor  circulation  through  this 
part  because  the  blood-vessels  are  more  easily  injected  in  a  moder- 
ately distended,  than  in  an  empty,  stomach. 

"  In  the  intestine  it  is  found  that  the  longitudinal  and  circular 
muscle-fibers  are  antagonistic.  In  the  stomach  the  pyloric  valve 
is  closed,  after  the  muscle-cells  are  dead,  by  a  fold  of  mucous  mem- 
brane being  thrown  into  the  lumen.  This  may  take  place  in  a 
living  stomach.  A  contraction  of  the  circular  muscle  tends  to 
strengthen  this  valve,  while  a  contraction  of  the  longitudinal  muscle 
tends  to  weaken  it,  because  with  the  contraction  of  the  longitudinal 
muscle  there  is  always  an  accompanying  relaxation  of  the  circular 
muscle.  Under  ordinary  circumstances  it  seems  as  though  the 
stomach  reduced  its  lumen  by  simultaneous  contraction  of  both 
longitudinal  and  circular  muscle-fibers.  What  complex  motions 
take  place  during  peristalsis  are  absolutely  unknown.  It  is,  how- 
ever, a  remarkable  fact,  that  a  bundle  of  the  circular  fibers  (oblique 
fibers)  are  parallel  with  the  longitudinal  fibers,  which  are  increased 
in  number  in  the  middle  zone.  A  solution  of  this  problem  seems 
within  the  range  of  experimentation. 

"  The  celiac  axis  supplies,  besides  the  stomach,  also  the  spleen 
and  the  hver.  With  a  given  pressure  within  the  aorta,  variation  m 
the  resistance  in  the  capillaries  of  the  spleen  and  the  liver  will  have 
a  marked  effect  upon  the  circulation  through  the  stomach.  The 
portion  of  the  stomach  (middle  zone)  supplied  by  the  gastric  artery 
is  to  a  less  extent  under  the  control  of  these  side  influences  than  is 
that  which  is  supplied  by  arteries  arising  from  the  main  branches 
to  the  spleen  and  to  the  liver.  It  must  be  again  stated,  that  there 
are,  in  all  probability,  many  other  influences  which  play  most  im- 
portant parts  in  the  distribution  of  blood. 

"  7.  Around  the  two  curvatures  of  the  stomach  there  is  a  com- 
plete circle  of  anastomosis,  which  has  a  tendency  to  equalize  the 
pressure  in  the  arteries  penetrating  the  muscle-walls.  But  the 
anastomoses  arising  therefrom  have  only  a  tendency  to  make 
gradual  gradations,  and  not  an  equal  pressure  throughout.  The 
additional  set  of  anastomoses  within  the  submucosa  are,  again,  not 
sufficient  to  equalize  the  flow  throughout  the  whole  mucosa. 
After  ligating  arteries,  as  well  as  by  examining  the  mucous  mem- 
3 


30  HISTOLOGY    OF    THE    STOMACH. 

brane  during  digestion  and  rest,  it  is  found  that  no  sharp  lines  can 
be  drawn. 

*'  8.  The  blood-vessels  are  arranged  in  such  a  manner  that  from 
any  portion  of  thesubmucosa  about  one-fourth  of  the  blood  may 
go  to  the  muscle-coats  and  three-fourths  to  the  mucosa.  It  is 
therefore  probable  that  when  the  flow  is  poured  to  one  side  it  is 
diminished  to  the  other,  and  vice  versa.  There  is,  however,  a  ten- 
dency to  equalize  this  by  the  submucous  anastomoses. 

"  9.  Since  there  is  but  one  set  of  arteries  to  the  mucosa,  there 
must  be  but  one  sort  of  circulation,  which  may  vary  in  degree 
only.  Within  the  mucosa  the  arrangement  is  such  that  the  portion 
of  the  gland  which  is  deepest  receives  the  blood  richest  in  O.  The 
mucous  membrane,  omitting  the  muscularis  mucosae,  lies  between 
two  venous  plexuses.  Contraction  of  the  muscle-fibers  between 
the  glands  and  those  of  the  muscularis  mucosae  should  diminish 
the  volume  of  the  mucosa.  This  would  have  a  tendency  to  empty 
the  glands,  as  well  as  to  press  blood  from  the  two  venous  plexuses, 
especially  the  lower.  Whether  or  not  there  is  a  force  within  the 
mucosa  which  can  augment  the  circulation,  seems  at  present  im- 
possible to  determine  by  experiment.  The  arrangement  of  the 
parts  is  very  suggestive. 

"  10.  The  rich  venous  plexus  of  veins  within  the  submucosa  is 
sufficiently  large  to  hold  a  considerable  quantity  of  blood.  This 
must  be  the  case  when  the  valves  within  the  veins  coming  from 
the  stomach  are  temporarily  closed.  When  the  valves  are  closed 
a  contraction  of  the  circular  muscle  is  sufficient  to  drive  all  the 
blood  from  the  underlying  veins.  It  is  therefore  possible  that  a 
rhythmic  contraction  in  any  part  of  the  stomach  may  favor  the  cir- 
culation through  its  walls. 

"  II.  The  arrangement  of  the  lymphatics  is  much  the  same  as 
that  of  the  veins,  and  the  above  consideration  (10)  applies  equally 
well  to  them.  When  we  consider  the  resistance  to  be  overcome 
while  the  lymph  passes  through  so  many  networks  before  the  cis- 
terna  chyli  is  reached,  it  makes  it  plausible  to  state  that  the  circu- 
lation is  favored  by  muscular  contraction. 

"  12.  Since  the  blood  which  leaves  the  stomach  must  pass 
through  the  capillaries  of  the  liver,  it  is  necessary  that  it  be  con- 
stantly under  a  comparatively  high  pressure.  This  pressure  is  also 
dependent  upon  the  spleen  and  the  intestine.     If  the   pressure  is 


VESSELS    AND    NERVES.  3 1 

high,  a  regurgitation  into  the  stomach  is  impossible  on  account  of 
the  presence  of  valves. 

"  13.  In  a  stomach  in  which  the  vessels  are  all  equally  distended 
the  rapidity  of  circulation  in  the  celiac  axis  would  be  263  times 
that  in  the  capillaries.  The  area  of  the  section  of  the  celiac  axis 
is  .0592  square  cm. ;  the  immediate  branches  to  the  stomach,  .0348 
square  cm. ;  to  the  spleen  and  liver,  .0244  square  cm.  All  the 
capillaries  of  the  stomach:  mucosa,  6.4524  square  cm.;  muscle- 
coats,  2.7214  square  cm.;  total,  9.1738  square  cm.  9.1738  h- 
.0348  =  263. 

"  A  like  estimation  shows  that  the  rapidity  of  circulation  in  all 
the  capillaries  is  gig  of  that  in  the  arteries  penetrating  the  muscle- 
walls ;  while  if  the  capillaries  of  the  muscle-walls  are  excluded, 
the  rapidity  in  the  capillaries  of  the  mucosa  rises  to  ^-^. 

"Considering  the  glands  on  an  average  .05  cm.  long  and  .003^ 
cm.  in  diameter,  excluding  the  necks,  the  area  of  all  the  glands 
would  be  8671  square  cm.,  or  38  times  the  area  of  mucous  mem- 
brane. A  like  estimation  of  the  capillaries,  considering  each 
capillary  .04  cm.  long,  gives  for  them  a  total  area  of  17 18  square 
cm.,  or  yy^  times  the  mucous  surface.  The  secreting  surface  is 
five  times  that  of  the  blood-supply." 

Vessels  and  Nerves. — The  arteries  supplying  the  stomach  are : 
the  coronaria  ventriculi ;  the  pyloric  and  right  gastro-epiploic 
branches  of  the  hepatic ;  the  left  gastro-epiploic  and  vasa  brevia 
from  the  splenic.  They  supply  the  muscular  coat,  ramify  in  the 
submucous  coat,  and  are  finally  distributed  to  the  mucous  mem- 
brane. The  arrangement  of  the  vessels  in  the  mucous  membrane 
is  somewhat  peculiar.  The  arteries  break  up  at  the  base  of  the 
gastric  tubules  into  a  plexus  of  fine  capillaries,  which  run  upward 
between  the  tubules,  anastomosing  with  each  other  and  ending  in 
a  plexus  of  large  capillaries,  which  surround  the  mouths  of  the 
tubes,  and  also  form  hexagonal  meshes  around  the  alveoli.  See 
Plate  II.  The  veins  arise  from  the  latter,  and  pursue  a  straight 
course  back  to  the  submucous  tissue,  between  the  tubules,  to 
terminate  in  the  splenic  and  portal  veins. 

The  lymphatics  are  abundant,  and  may  be  divided  into  a  super- 
ficial and  a  deep  set,  which  pass  through  the  lymphatic  glands  found 
along-  the  two  curvatures.  The  nerves  are  supplied  from  the  right 
and  left  pneumogastric,  and  numerous  branches  from  the  abdomi- 
nal sympathetics.     (Solar  plexus.) 


CHAPTER  III. 

THE  SMALL  INTESTINE.   . 

The  small  intestine  commences  at  the  pylorus,  and,  after  many 
convolutions,  terminates  in  the  large  intestine.  It  measures,  on  an 
average,  about  22  feet  in  length  in  an  adult,  and  becomes  gradually 
narrower  from  its  upper  to  its  lower  end.  Its  convolutions  occupy 
the  middle  and  lower  parts  of  the  abdomen,  frequently  descending 
into  the  pelvis. 

The  small  intestine  is  divided  into  three  portions,  which  have  re- 
ceived different  names.  The  first  10  to  12  inches  immediately 
succeeding  the  stomach,  and  comprising  the  widest  and  most  fixed 
part  of  the  tube,  are  called  the  duodenum.  This  part  is  further 
distinguished  by  its  close  relation  to  the  head  of  the  pancreas,  and 
by  the  absence  of  a  mesentery.  The  remainder,  which  is  arbitrarily 
divided  into  an  upper  two-fifths,  called  the  jejunum,  and  a  lower 
three-fifths,  called  the  ileum,  is  very  convoluted  and  movable,  being 
connected  with  the  posterior  abdominal  wall  by  a  long  and  exten- 
sive fold  of  peritoneum  called  the  mesentery,  and  by  numerous 
blood-vessels  and  nerves.  Although  there  is  no  distinct  line  of  de- 
marcation between  the  jejunum  and  the  ileum,  yet  that  portion  of 
the  small  intestine  included  under  these  two  names  gradually  un- 
dergoes certain  changes  in  structure  and  appearance  from  above 
downward,  so  that  the  upper  end  of  the  jejunum  can  readily  be  dis- 
tinguished from  the  lower  end  of  the  ileum. 

Structure  of  the  Small  Intestine. — The  small  intestine,  like 
the  stomach,  is  composed  of  four  coats,  viz. :  the  serous  or  peri- 
toneal, the  muscular,  the  areolar,  and  the  mucous. 

The  external,  or  serous,  coat  almost  entirely  surrounds  the  intes- 
tinal tube  in  the  whole  extent  of  jejunum  and  ileum,  leaving  only  a 
narrow  interval  behind,  where  it  passes  off  and  becomes  continuous 
with  the  two  layers  of  the  mesentery.  The  line  at  which  this  takes 
place  is  named  the  attached  or  mesenteric  border  of  the  intestine. 
The  duodenum,  on  the  other  hand,  is  but  partially  covered  by  the 
peritoneum.     The  muscular  coat  consists  of  two  layers  of  fibers — an 

32 


STRUCTURE    OF    SMALL    INTESTINE.  33 

outer  longitudinal,  and  an  inner,  or  circular,  set.  The  longitudinal 
fibers  constitute  an  entire  but  comparatively  thin  layer  and  are 
most  obvious  along  the  free  border  of  the  intestine.  The  circular 
layer  is  thicker  and  more  distinct. 

The  muscular  tunic  becomes  gradually  thinner  toward  the  lower 
part  of  the  small  intestine.  It  is  pale  in  color,  and  is  composed  of 
plain  muscular  tissue,  the  cells  of  which  are  of  considerable  length. 

The  progressive  contraction  of  these  fibers,  commencing  at  any 
part  of  the  intestine,  and  advancing  in  a  downward  direction,  pro- 
duces the  peculiar  vermicular,  or  peristaltic,  movement  by  which  the 
contents  are  forced  onward  through  the  canal.  In  the  narrowing 
of  the  tube  the  circular  fibers  are  mainly  concerned,  the  longitudinal 
fibers  tending  to  produce  dilatation  (Exner) ;  and  those  found  along 
the  free  border  of  the  intestine  may  have  the  effect  of  straightening 
or  unfolding  its  successive  convolutions.  There  is  a  gangliated 
plexus  of  nerve-fibers  and  a  network  of  lymphatic  vessels  between 
the  two  muscular  layers. 

The  submucous  coat  of  the  small  intestine  is  a  layer  of  areolar 
tissue  of  a  loose  texture,  which  is  connected  more  firmly  with  the 
mucous  than  with  the  muscular  coat.  Within  it  the  blood-vessels 
ramify  before  passing  to  the  mucous  membrane,  and  it  contains  a 
gangliated  plexus  of  nerve-fibers  and  a  network  of  large  lymphatic 
vessels. 

The  internal  coat,  or  mucous  membrane,  is  characterized  by  the 
finely  flocculent,  or  shaggy,  appearance  of  its  inner  surface,  resem- 
bling the  pile  upon  velvet.  This  appearance  is  due  to  the  surface 
being  thickly  covered  with  minute  processes,  named  villi.  It  is  one 
of  the  most  vascular  membranes  in  the  body,  and  is  naturally  of  a 
reddish  color  in  the  upper  part  of  the  small  intestine,  but  is  paler, 
and  at  the  same  time  thinner,  toward  the  lower  end.  It  is  lined 
with  columnar  epithelium  throughout  its  whole  extent,  and,  next  to 
the  submucous  coat,  is  bounded  by  a  layer  of  plain  muscular  tissue 
(muscularis  mucosa);  between  this  and  the  epithelium  the  substance 
of  the  membrane,  apart  from  the  tubular  glands,  which  will  be  after- 
ward described,  consists  mainly  of  retiform  tissue,  which  supports 
the  blood-vessel,  nerves,  lymphatics,  and  lacteals,  and  incloses  in  its 
meshes  numerous  lymph-corpuscles. 

Valvulae  Conniventes. — The  mucous  membrane,  in  addition  to 
small  effaceable  folds,  or  rugae,  possesses  also  permanent  folds, 
which  can   not  be  obliterated,  even  when  the  tube  is  forcibly  dis 


34  THE    SMALL    INTESTINE. 

tended.  These  permanent  folds  are  the  \-alvul3e  conniventes,  or 
valves  of  Kerkring.  They  are  crescentic  projections  of  the  mucous 
membrane,  placed  transversely  to  the  axis  of  the  bowel,  and  follow- 
ing one  another  closeK'.  The  majority  of  the  folds  do  not  extend 
more  than  one-half  or  two-thirds  around  the  interior  of  the  tube, 
but  it  has  been  shown  by  Brooks  and  Kazzander  that  some  form 
complete  circles,  and  others  spirals.  The  spiral  forms  may  occur 
singly  or  in  groups  of  two  or  three.  They  generally  extend  a  little 
more  than  once  around  the  lumen  of  the  bowel,  but  in  rare  cases 
may  go  around  two  or  three  times.  At  their  highest  point  they 
project  inward  for  about  I3  of  an  inch.  Some  of  the  valvulse  con- 
niventes are  bifurcated  at  one  or  both  ends,  and  others  terminate 
abruptly.  Each  consists  of  a  fold  of  mucous  membrane,  that  is,  of 
two  layers  placed  back  to  back,  and  united  together  by  submucous 
areolar  tissue.  They  contain  no  part  of  the  circular  or  longitudinal 
muscular  coats.  Being  extensions  of  the  mucous  membrane,  they 
serve  to  increase  the  absorbent  surface  to  which  the  food  is  ex- 
posed. 

The  valvulse  conniventes  are  not  uniformly  distributed  over  the 
various  parts  of  the  small  intestine.  There  are  none  just  at  the 
commencement  of  the  duodenum  ;  a  short  distance  from  the  p\-lorus 
they  begin  to  appear  ;  beyond  the  point  at  which  the  bile  and  pan- 
creatic juice  are  poured  into  the  duodenum,  the}'  are  very  large, 
regularly  crescentic  in  form,  and  placed  so  near  to  each  other  that 
the  intervals  between  them  are  not  greater  than  the  breadth  of  the 
valves;  they  continue  thus  through  the  rest  of  the  duodenum,  and 
along  the  upper  half  of  the  jejunum  ;  below  that  point  they  begin 
to  get  smaller  and  farther  apart,  and,  finally,  toward  the  middle  or 
lower  end  of  the  ileum,  having  gradually  become  more  irregular 
and  indistinct,  sometimes  even  acquiring  a  very  oblique  direction, 
they  disappear  altogether. 

The  villi,  peculiar  to  the  small  intestine,  and  giving  to  its  inter- 
nal surface  the  velvety  appearance  already  spoken  of,  are  small  pro- 
cesses of  the  mucous  membrane,  which  are  closely  set  on  every 
part  of  the  inner  surface  over  the  valvulse  conniventes,  as  well  as 
between  them.  Their  length  varies  from  0.5  mm.  to  0.7  mm.,  or 
sometimes  more. 

They  are  largest  and  most  numerous  in  the  duodenum  and  jeju- 
num, and  become  gradually  smaller,  and  fewer  in  number,  in  the 
ileum.     According  to  Rauber,  they  are  short  and  leaf-shaped  in  the 


THE    VILLI.  35 

duodenum,  and  as  the  gut  is  followed  downward  they  become 
gradually  longer  and  thinner,  so  that  they  are  tongue-shaped  in  the 
jejunum  and  filiform  in  the  ileum.  Occasionally  two  or  three  are 
connected  together  at  their  bases.  In  the  upper  part  of  the  small 
intestine  there  are  from  lo  to  i8  villi  in  a  square  millimeter,  and  in 
the  ileum  from  8  to  14  in  the  same  space.  This  would  give  about 
4,000,000  altogether  (Krause). 

A  villus  consists  of  a  prolongation  of  the  proper  mucous  mem- 
brane. It  is  covered  by  columnar  epithelium,  and  incloses  a  net- 
work of  blood-vessels,  one  or  more  lymphatic  vessels  (lacteals),  and 
a  few  longitudinal,  plain,  muscular  fiber-cells,  these  being  all  sup- 
ported and  held  together  by  retiform  lymphoid  tissue. 

Under  the  epithelium  is  a  basement  membrane  composed  of 
flattened  cells,  which,  on  the  one  hand,  are  connected  with  the 
branched  cells  of  the  retiform  tissue,  and,  on  the  other  hand,  send 
processes  between  the  epithelial  cells.  Nervous  fibrils  penetrate 
into  the  villi  from  the  plexus  of  Meissner,  and  form  arborizations 
throughout  their  whole  substance. 

Each  villus  receives,  as  a  rule,  one  small  arterial  twig,  which  runs 
from  the  submucous  coat,  through  the  muscularis  mucosae,  to  the 
base  of  the  villus,  and  then  up  the  center  to  near  the  middle  line  of 
the  villus,  where  it  begins  to  break  up  into  a  number  of  capillaries. 

These  form,  near  the  surface,  a  fine  capillary  network  beneath 
the  epithelium  and  limiting  membrane,  from  which  the  blood  is 
returned,  for  the  most  part,  by  one  or  two  venules,  which,  in  man, 
commence  near  the  tip  of  the  villus,  and  pass  down  to  its  base  to 
join  the  venous  plexus  of  the  mucous  membrane,  whence  the  blood 
is  conveyed  to  the  large  veins  of  the  submucosa. 

The  Lacteal  lies  in  the  center  of  the  villus,  and,  in  the  smaller 
villi,  is  usually  a  single  vessel  with  a  closed  and  somewhat  expanded 
extremity,  and  of  considerably  larger  diameter  than  the  capillaries 
of  the  blood-vessels  around.  In  the  human  subject  there  are  never 
more  than  two  intercommunicating  lacteals  in  a  single  villus. 

The  lacteals  in  the  villi  are  bounded  by  a  delicate  layer  of  flat- 
tened epithelial  cells;  these  are  connected  with  the  branched  cells 
of  the  tissue  of  the  villus,  and  these  again  with  the  flattened 
cells  forming  the  basement  membrane ;  from  the  latter,  pro- 
longations extend  between  the  epithelial  cells  toward  the  surface. 
Briicke  first  discovered  the  muscular  tissue  within  the  villus, 
consisting  of  unstriated,  plain   fiber-cells,  disposed   longitudinally 


36  THE    SMALL    INTESTINE. 

around   the  lacteal.     These  fibers  are  prolongations  of  the  mus- 
cularis  mucosae. 

When  they  are  stimulated  in  animals  a  very  evident  retraction 
of  the  villus  is  observable. 

The  fiber-cells  at  the  sides  and  toward  the  end  of  the  villus  pass 
from  the  lacteal  to  be  attached  to  the  basement  membrane  in  a 
bifurcating  manner. 

Columnar  epithelial  cells  cover  not  only  the  villi,  but  also  the 
rest  of  the  surface  of  the  small  intestine,  and  extend  into  the  tubular 
glands.  There  is  never  any  continuity  between  the  extremity  that 
is  attached  to  the  basement  membrane  and  the  branched  corpuscles 
of  the  retiform  tissue  of  the  villus.  This  epithelium  separates  easily 
from  the  subjacent  tissue.  Between  the  cells  composing  it  are  a 
variable  number  of  leucocytes,  most  numerous  in  the  lower  part  of 
the  intestines  near  the  lymphoid  follicles.  Occasionally  they  are 
seen  to  be  free  in  small  lymph-spaces  between  the  columnar  epi- 
thelial cells  and  showing  indications  of  karyokinesis.  Hardy  de- 
clares that  immediately  below  the  columnar  epithelium  of  the  villi 
there  is  frequently  a  well-marked  layer  of  cells  that  take  up  the 
eosin  stain  readily.     Hence  he  calls  them  eosinophilic. 

Among  the  ordinary  epithelial  cells  of  the  villus  are  others,  the 
outer  half  of  which  is  filled  with  mucigen,  and  at  times  beaker- 
or  cup-shaped  empty  cells  are  observed  from  which  this  has 
been  discharged  as  mucus,  the  free  end  being  ruptured ;  these  are 
sometimes  called  the  goblet-cells.  The  number  of  cells  containing 
mucus  varies  much  in  different  animals  and  under  different  condi- 
tions in  the  same  animal.  There  are  comparatively  few  mucous 
cells  in  the  glands  of  the  small  intestine. 

The  epithelial  cells  are,  as  far  as  can  be  ascertained,  the  principal 
agents  in  promoting  the  absorption  of  food  materials  from  the  in- 
terior of  the  gut,  and  the  seat  of  the  retrograde  processes  of  meta- 
bolism which  the  products  of  digestion  undergo  during  absorption. 
Peptone,  when  injected  into  the  blood  of  an  animal  by  whose  gastric 
juice  it  has  been  formed,  acts  as  a  poison.  It  is  due  to  these 
epithelial  cells  of  the  intestine  that  peptone  is  so  modified  during 
absorption  that  it  becomes  of  use  to  the  organism. 

Most  food  particles  can  not  be  traced  in  microscopic  specimens, 
but  fatty  or  oily  substances,  from  their  property  of  becoming 
stained  with  osmic  acid,  can  be,  to  some  extent,  followed  out.  The 
examination  of  such  specimens,  taken  during  digestion  of  a  meal 


GLANDS.  37 

containing^  fat,  shows  the  epithehal  cells  turbid  with  oil  droplets  in 
their  interior  ;  and  in  some  animals,  at  a  subsequent  stage,  ameboid 
cells  appear  within  the  tissue  of  the  villus  pervaded  with  similar 
but  finer  fatty  particles,  and  eventually  the  central  lacteal  becomes 
filled  with  these.  It  is  probable  that  these  ameboid  lymph-corpus- 
cles, appearing-  so  abundantly  within  the  villus  and  among  the  epi- 
thelial cells  on  its  surface,  play  an  important  part  in  the  transfer- 
ence of  such  particles  from  the  epithelial  cells  in  the  lacteal;  for 
at  certain  stages  of  fat  absorption  they  contain  abundant  fatty  par- 
ticles. The  large  amount  of  lymphoid  tissue  in  the  lower  part  of 
the  small  intestine  seems  to  be  related  to  a  greater  power  of 
absorption  in  that  part. 

In  the  transference  of  carbon  particles  in  the  lungs,  from  the 
interior  of  the  alveoli  into  the  lymphatics,  which  at  least  in  part  is 
due  to  the  action  of  ameboid  cells,  we  have  an  analogous  process. 

Glands. — Two  kinds  of  true  secreting  glands  are  found  in  the 
intestine;  these  are:  (i)  the  glands  or  crypts  of  Lieberkiihn  and 
(2)  glands  of  Brunner.  In  addition  to  these,  there  are  found  also 
two  varieties  of  intestinal  lymph-follicles,  (i)  the  solitary  and  (2) 
the  agminate  glands,  the  latter  often  designated  as  Peyer's  patches. 

Although  the  solitary  and  agminated  lymph-follicles  have  no 
ducts  opening  upon  the  inner  intestinal  surfaces,  like  Brunner's 
and  Lieberkiihn's  glands,  they  are  nevertheless  spoken  of  as  glands. 

The  follicles,  crypts,  or  glands  of  Lieberkiihn  are  tubular  pits 
lined  by  columnar  epithelium,  occurring  between  the  villi  and  on 
the  valvulse  conniventes.  Here  and  there  in  these  crypts,  goblet- 
cells  occur  in  the  epithelium.  They  are  present  throughout  the 
large  and  small  intestine,  and  extend  through  the  entire  depth  of 
the  mucosa,  their  ends  approaching  the  muscularis  mucosae. 

The  duodenum  possesses  an  additional  layer  of  true  secreting 
structures  in  the  glands  of  Brunner.  They  would  appear  to  rep- 
resent the  direct  continuations  and  higher  specializations  of  the 
pyloric  glands.  In  passing  from  the  stomach  into  the  intestines, 
these  tubules  undergo  repeated  division,  at  the  same  time  sinking 
deeper  into  the  mucosa,  finally  reaching  below  this  layer  to  take 
up  a  position  within  the  submucosa  of  the  duodenum,  underneath 
the  overlying  layer  of  the  crypts  of  Lieberkiihn,  which  are  con- 
tained in  the  mucosa  proper.  Brunner's  glands  belong  to  the  race- 
mose type,  and  under  the  microscope  they  consist  of  a  number  of 
tubular  alveoli  connected  by  terminal   ramifications   of  the   duct 


30  THE    SMALL    INTESTINE. 

which  penetrates  the  muscularis  mucosae,  and  opens  either  between 
the  mouths  of  the  Lieberkijhn  crypts  or  sometimes  into  their 
bases. 

The  soHtary  glands  are  isolated  lymph-follicles  scattered  through 
the  entire  intestine,  most  abundant  in  the  lower  ileum.  Situated  in 
the  mucosa,  at  times  in  the  submucosa,  the  lymphoid  tissue  in  them 
is  denser  toward  the  periphery,  but  is  everywhere  so  closely 
packed  that  the  supporting  reticulum  of  connective  tissue  is 
masked. 

The  agminated  glands,  or  Peyer's  patches,  are  large  oval  aggre- 
gations of  lymph-follicles  held  together  by  diffuse  adenoid  tissue, 
limited  to  the  lower  two-thirds  of  the  small  intestine.  Develop- 
ment of  these  is  most  perfect  in  the  ileum;  appearing  first  within 
the  mucosa,  they  later  encroach  upon  the  submucous  tissue. 

Where  the  summits  of  these  follicles  impinge  against  the  inner 
layer  of  the  mucosa,  the  position  of  the  agminated  glands  is  indi- 
cated by  an  elevation  corresponding  to  them  on  the  mucous  sur- 
face.    In  that  case  the  villi  are  frequently  pushed  aside. 

The  Blood-vessels  of  the  Intestines. — The  vessels  follow 
the  general  arrangement  of  those  in  the  stomach,  the  larger  ones 
piercing  the  serous  and  muscular  coat,  giving  off  slender  twigs  to 
supply  these  tunics,  and  when  they  enter  the  submucosa,  the  ves- 
sels form  a  wide-meshed  network.  Many  branches  then  pass 
through  the  muscularis  mucosae,  to  be  distributed  to  the  deeper,  as 
well  as  the  superficial,  part  of  the  mucosa.  Around  the  tubular 
glands  a  network  is  formed  by  narrow  capillaries,  and  just  beneath 
the  epithelium  the  capillaries  become  wider  and  encircle  the  mouths 
of  the  follicles.  From  this  superficial  capillary  network  the  veins 
arise,  and,  passing  down  between  the  follicles,  join  the  deeper 
venous  plexus,  this  in  turn  communicating  with  the  larger  veins  of 
the  submucosa. 

The  villi  have  special  additional  arteries  running  to  their  bases, 
expanding  into  capillaries,  and  then  extending  beneath  the  epithe- 
lium and  around  the  central  lacteal  as  far  as  the  ends  of  the  villi. 
These  capillaries  terminate  in  venous  stems  which  descend  almost 
perpendicularly  into  the  mucosa,  in  their  course  receiving  the 
superficial  capillaries  encircling  the  gland  ducts.  Brunner's  glands, 
and  the  solitary  and  agminated  follicles,  are  supplied  from  the  sub- 
mucosa by  vessels  terminating  in  capillary  networks  distributed  to 
the  acini  of  the  glands  and  interior  of  the  lymph-follicles. 


LYMPH- VESSELS DUODENUM.  39 

The  blood-vessels  of  the  intestines,  taken  as  a  whole,  constitute 
a  mighty  vascular  territory  which  is  capable  of  taking  up  one-third 
of  the  total  amount  of  blood  of  the  body. 

The  arteries  are  all  branches  of  the  superior  and  inferior  mesen- 
teric arteries,  which  run  along  and  approach  the  gut  in  the  mesen- 
tery. The  intestinal  veins  form  the  principal  portion  of  the  portal 
system. 

Lymph-vessels. — The  beginning  of  the  lymph-vessels  can  be 
traced  to  the  lacteals  within  the  villi,  where  they  begin  as  tiny,  little 
blind  pouches  at  the  apex  of  the  villus.  In  some  broad  villi  there 
are  two  or  three  such  lymph-vessels  that  anastomose  with  each 
other.  From  here  they  run  down  in  the  septa  between  the 
glands  in  the  lymph-vessel  meshwork  over  the  muscularis  mucosae. 
Here  they  again  anastomose  with  an  outer  lymph-vessel  network 
in  the  submucosa.  Here  the  lymphatics  begin  to  be  provided 
with  valves. 

The  nerves  of  the  intestine,  like  those  of  the  stomach,  originate 
chiefly  from  the  mesenteric  plexus,  which  is  formed  by  branches 
from  the  celiac  plexus,  the  semilunar  ganglion,  and  vagus  nerve; 
consisting  of  meduUated  and  non-meduUated  fibers,  that  begin  to 
form  an  abundant  network  under  the  peritoneum  of  the  intestine, 
then  penetrate  the  longitudinal  muscular  stratum,  and  between  this 
and  the  circular  layer  form  a  peculiar  plexus  with  numerous  micro- 
scopic ganglia,  constituting  the  plexus  of  Auerbach. 

In  the  submucosa  a  similar  network  of  fibers  and  ganglia  has 
been  termed  Meissner's  plexus.  From  Meissner's  plexus  very  fine 
fibers  are  spun  about  the  Lieberkiihn  crypts,  villi,  and  limiting 
membrane. 

Relations  of  the  Duodenum. — This  part  of  the  gut  in  the  adult 
is  horseshoe-shaped,  generally  presenting  well-marked  angles, 
which  divide  it  into  four  parts  having  four  distinct  directions  ;  these 
are:  (i)  The  horizontal  or  superior  part,  running  backward  from 
the  pylorus,  to  the  right,  in  contact  with  the  quadrate  lobe  of  the 
liver,  to  the  under  side  of  the  neck  of  the  gall-bladder,  where  it 
curves  sharply  downward  to  join  the  second  part.  This  first  or 
horizontal  part  is  about  two  inches  long  when  the  stomach  is 
empty.  (2)  The  second  or  descending  portion  is  about  three  inches 
long,  and  commences  just  below  the  neck  of  the  gall-bladder 
opposite  the  right  side  of  the  first  lumbar  vertebra,  and  passes  down 
to  the  level  of  the  third  or  fourth  lumbar  vertebra,  where  it  turns 


40 


THE    SMALL    INTESTINE. 


sharply  inward  to  join  the  third  part.  (3)  The  third  or  transverse 
portion  is  from  two  to  three  inches  long  ;  beginning  at  the  right 
of  the  third  or  fourth  lumbar  vertebra,  it  crosses  over  to  the  left 
side  with  a  slight  upward  inclination,  and  ends  to  the  left  of  the 
aorta  by  curving  upward  to  join  the  terminal,  (4;  fourth,  or  ascend- 
ing, portion,  which  is  about  two  inches  long;  it  passes  upward  to 
the  left  side  of  the  aorta,  as  high  as  the  upper  border  of  the  second 
lumbar  vertebra  ;  here  it  turns  abruptly  forward  to  join  the  jeju- 
num, forming  the  duodenojeiunal  fleNure. 


Fig.  4. — Plaster  Cast  of  Duodenum  of  Infant  and  Adult. — (From  Museum  of  Harvard 

University). 
A.  Infant  duodenum.     B.  Adult.     V.  Valvulae  conniventes.     P.  Pylorus. 


Thus  the  end  of  the  duodenum  is  brought  to  the  same  level  as 
the  beginning.  It  has  been  compared  to  a  water-trap,  its  ends  being 
always  higher  than  its  middle,  which  is  thus  fitted  to  retain  the 
fluid  poured  into  it  from  the  liver,  pancreas,  and  its  own  glands, 
besides  that  which  it  receives  from  the  stomach,  at  the  same  time 
preventing  the  regurgitation  of  gases  from  the  jejunum  into  the 
pyloric  part  of  the  duodenum  and  stomach. 


JEJUNUiM    AND    ILEUM.  4 1 

Jejunum  and  Ileum. — The  upper  two-fifths  of  the  remaining 
intestine  immediately  following  the  duodenum  are  called  the 
jejunum,  the  lower  three-fifths,  the  ileum.  Both  are  attached  to 
the  posterior  abdominal  wall  b}-  an  extensive  fold  of  peritoneum, 
— the  mesentery. 

The  jejunum  lies  above  and  to  the  left  of  the  ileum,  but  the  coils 
are  so  irregular  that  the  position  of  any  individual  loop  affords  but 
little  clue  to  the  part  of  the  intestine  to  which  it  belongs. 

The  large  intestine  consists  of  the  cecum,  the  colon,  and  the 
rectum.  The  colon  is  subdivided,  according  to  the  directions  it 
takes,  into  four  parts,  which  are  (i)  the  ascending,  (2)  transverse, 
(3)  descending,  and  (4)  sigmoid  colon  or  flexure. 

The  end  of  the  ileum,  which  rises  out  of  the  pelvis  to  the  right 
iliac  fossa,  is  not  inserted  into  the  beginning  of  the  large  intestine, 
but  above  the  beginning  and  at  the  side  of  it.  The  part  of  the 
large  intestine  below  this  insertion  is  a  blind  pouch, — the  cecum. 
From  the  inner  and  back  part  of  the  cecum,  a  little  below  the  ileo- 
colic opening,  a  narrow,  round,  worm-like  process,  about  two  or 
three  inches  long,  is  given  off, — the  vermiform  appendix. 

The  cecum  continues  upward  into  the  ascending  colon,  which 
rises  up  in  front  of  the  right  kidney  to  the  edge  of  the  liver ;  then 
this  same  large  intestine  passes  beneath  the  greater  curvature  of  the 
stomach,  and  horizontally  across  to  the  left  side,  as  the  transverse 
colon ;  here,  at  the  lower  border  of  the  spleen,  it  turns  downward  as 
the  descending  colon. 

This  large  gut  describes  two  right-angled  curves,  the  right  and 
left  colonic  flexures  fixed  by  the  hepatocolic  and  gastrocolic  liga- 
ments respectively.  The  descending  colon  continues  into  the 
sigmoid  colon  or  flexure,  which  connects  it  with  the  rectum.  The 
rectum,  following  the  curves  of  the  sacro-iliac  symphysis  and  the 
hollow  of  the  sacrum,  has  itself  two  curves:  an  upper  larger  curve, 
concave  anteriorly,  and  a  lower  smaller  cur\'e,  convex  anteriorly. 

Only  the  cecum,  transverse  colon,  and  sigmoid  colon  have  a  com- 
plete peritoneal  covering ;  the  rest  of  the  large  gut  is  only  covered 
anteriorly.  From  the  third  sacral  vertebra  on,  the  rectum  has  no 
peritoneum.  Those  parts  having  no  complete  peritoneum,  therefore, 
have  no  mesentery,  and  are  not  very  movable.  The  longitudinal 
fibers  are  contracted,  or  narrowed,  down  to  three  parallel  bands 
(Fasciae  tenise,  or  lig.  coli).  One  of  these  bands  runs  along  the 
attachment   of  the   crastrocolic  ligament   on  the   transverse  colon 


42  THE   SMALL    INTESTIN?. 

(fascia  omentalis),  the  second  along  the  mesenteric  border,  and  the 
third  is  free. 

Running  down  into  the  rectum  these  bands  become  so  broad 
that  they  occupy  the  entire  periphery  of  the  tube.  These  longitud- 
inal bands  are  much  shorter  than  the  other  layers  of  the  intestinal 
wall,  which  arrangement  results  in  the  characteristic  sacculation  of 
the  large  intestine.  In  the  lower  part  of  the  rectum  the  circular 
muscular  layer  becomes  thickened  to  form  the  internal  anal  sphinc- 
ter of  involuntary  fibers. 

The  external  sphincter  is  composed  of  striated  voluntary  muscle- 
fibers.  The  histology  of  the  large  intestine  differs  from  that  of  the 
small  by  the  absence  of  the  villi  and  the  larger  size  of  the  crypts  and 
follicles.  Several  longitudinal  elevations  over  the  anus  are  called 
the  columns  of  Morgagni ;  from  this  point  downward  the  cylindrical 
epithelium  ceases  and  flat  pavement  epithelium  takes  its  place. 


CHAPTER  IV. 

PHYSIOLOGY  OF  DIGESTION. 

Food  Substances. — The  simple  chemical  elements  of  the  various 
food  substances,  namely,  C,  H,  X,  S,  and  P,  are  not  assimilable  as 
such,  because  the  human  body  is  not  capable  of  constructing  hicrher 
compounds  from  them  synthetically.  It  is  compelled  to  take  in 
these  compounds  in  the  form  of  proteid  or  albuminous  substances, 
carbohydrates,  or  starches  and  fats,  together  with  such  inorganic 
bodies  as  water  and  salts. 

Even  these  food-stuffs,  which  are  essential  for  the  maintenance 
and  development  of  the  organism,  are  not  ingested  as  such,  but  are 
contained,  together  with  innutritions  materials,  in  the  various 
articles  of  diet  which  we  deri\-e  from  the  animal  and  vegetable 
kingdom. 

The  innutritious  admixtures  of  the  food-substances  are  not 
harmful,  but  are  important  as  stimulants  to  the  intestinal  mucosa 
and  to  the  evacuation  of  feces.  Among  these  innutritious  sub- 
stances are  classed  the  connective  tissue,  the  cartilages  and  tendons 
of  meat,  and  the  cellulose  of  plants. 

Water  plays  a  most  important  role  in  the  economy  of  the  body, 
for  it  goes  to  make  up  60  per  cent,  of  the  total  organism.  We  lose 
about  25^  liters  of  water  in  twenty-four  hours,  through  insensible 
perspiration,  secretion,  and  defecation.  About  300-400  gms.  of 
water  are  formed  by  oxidation  of  food-substances  in  twenty-four 
hours;  so  we  have  a  deficit  of  1500-1600  gms.,  which  must  be 
supplied  by  the  daily  consumption  of  a  corresponding  amount  of 
water;  this  is  done  principally  by  the  drinking  of  water  after  we 
have  taken  in  part  of  it  by  our  foods  or  in  the  shape  of  beverages 
(soups,  milk,  fruits,  vegetables,  potatoes,  beer,  wine,  coffee,  tea,  etc.). 

In  mineral  substances  we  must  supply  the  daily  loss  of  sodium 
chlorid  and  other  salts,  particularly  compounds  of  iron  ;  these  are 
normally  introduced  in  sufficient  quantities  in  food  and  drink. 

The  chief  constituents  of  food — albuminous  bodies,  fats,  and 
carbohydrates — are  of  organic  nature.    The  proteids,  or  albuminous 

43 


44  PHYSIOLOGY    OF    DIGESTION. 

bodies,  and  the  fats,  are  derived  partly  from  the  animal  and  partly 
from  the  vegetable  kingdom.  The  carbohydrates  are  almost  exclu- 
sively derived  from  the  vegetable  kingdom.  The  former  serve  for  the 
building  up  of  the  organism,  and  the  continuance  of  life  processes. 
The  latter  are  producers  of  heat  by  their  oxidation,  which  finally 
reaches  HoCO;^  and  H2O.  and  are  the  prevailing  sources  of  work. 

In  addition  to  these  a  number  of  other  substances  occur  in  the 
food  that  are  oxidized,  and  might  serve  as  sources  of  energy  ;  these 
are  the  nitrogen-free  vegetable  acids,  the  amido-acids,  and  alcohol, 
for  instance;  quantitatively,  however,  they  are  not  important. 

Other  organic  bodies  that  are  contained  in  food  materials  as 
normal  constituents,  such  as  creatin  in  meat,  glucosides,  alkaloids, 
and  ethereal  oils  in  vegetables  and  spices,  pass  through  the  body 
without  being  oxidized  or  assimilated ;  they  are  not  food-sub- 
stances, as  they  do  not  enter  the  metabolism  of  the  body,  nor  do 
they  develop  energy  by  chemical  transformation.  However,  a 
number  of  these  are  of  importance  in  nutrition,  as  they  render  the 
food  more  palatable,  and  stimulate  the  secretions  and  the  motility 
of  the  digestive  tract. 

It  has  been  said  that  the  elements  S,  P,  CI,  K,  Na,  Ca,  Fe,  Mg, 
are  not  food-materials,  but  it  must  not  be  understood  that  they  are 
entirely  useless.  They  have  some  significance  in  the  construction 
of  tissue,  although  the  organism  can  derive  no  energy  from  them, 
as  they  are  always  taken  in  a  highly  oxidized  state,  and  leave  in 
the  same  condition.  Nevertheless,  the  body  will  come  to  grief,  if 
any  one  of  these  elements  be  excluded  from  the  food. 

A  certain  minimum  of  these  elements — the  amount  has  not  yet 
been  ascertained — is  absolutely  necessary.  Outside  of  the  sub- 
stances named  above,  the  food  contains  a  number  of  materials  that 
are  not  at  all  absorbable  or  digestible,  and  leave  the  digestive  tract 
in  an  unchanged  form  ;  this  is  the  slag  and  dross  of  the  food,  and 
is  taken  into  the  body  principally  with  vegetables. 

The  normal  adult  human  organism  daily  loses  by  its  metabo- 
lism 120  gm.  of  albuminous  or  proteid  bodies,  80  gm.  fat,  400  gm. 
carbohydrates,  25  gm.  salts,  and  2^  liters  of  water.  Accordingly, 
a  corresponding  amount  of  food-stuffs  must  be  introduced  in  the 
diet.  The  articles  of  food  contain  these  nutritious  substances  in  a 
variety  of  proportions.  The  rational  combination  of  these  sub- 
stances is  one  of  the  objects  of  dietetics.  Oilman  Thompson,  in  his 
new  book  on  "  Dietetics,"  divides  foods  into  six  groups,  as  follows: 


CALORIC    VALUES.  45 

L  Water,   n.  Salts,    in.  Proteids    (chiefly    albuminous    and   allied 
gelatines),  iv.  Starches,  v.  Sugar,  vi.  Fats  and  oils. 

It  still  remains  extremely  difficult,  in  the  case  of  all  foods,  to 
trace  their  final  uses  in  the  body,  and  determine  with  any  accuracy 
what  proportions  each  furnish,  respectively,  of  energy,  repair  of 
tissue,  and  heat;  for  there  are  no  more  complex  chemical  processes 
known  than  those  of  metabolism  (Oilman  Thompson).  Foods 
have  three  kinds  of  values  :  (i)  nutrient,  (2)  heat-producing,  (3) 
force-producing. 

Caloric  Values. — The  calculation  of  these  different  values  for 
each  kind  of  food  has  been  much  simplified  by  the  introduction  of 
the  conception  of  calories  into  the  doctrines  of  nutrition.  Formerly, 
observers  and  investigators  said  :  "  A  healthy  man  needs  so  many 
gm.  proteid,  so  many  gm.  carbohydrates,  so  many  gm.  fat,"  etc.  It 
was  inconvenient  to  reckon  with  three  magnitudes  and  to  bring 
them  into  correct  relation  with  the  requisites  of  the  individual 
organism. 

Nowadays  we  compute  the  values  of  food-stuffs  according  to  the 
physiological  (kinetic)  energy  liberated  in  their  oxidation.  Ger- 
mans call  this  "  degree  of  energy,"  which  is  always  expressed  in 
terms  of  heat,  the  BrenmvertJi,  i.  e.,  the  value  of  food  when  it  is 
burned  in  the  process  of  metabolism,  for  this  is  nothing  but  a  slow 
combustion.  Now  the  unit  for  measurement  of  this  heat  energy  of 
food  is  called  a  calorie.  This  capacity  for  heat  production  of  foods 
is  determined  from  the  amount  of  heat  which  is  liberated  when  any 
particular  food-substance  is  transformed  from  its  original  composi- 
tion, when  it  entered  the  body — by  oxidation — into  those  chemical 
combinations  in  which  it  leaves  the  organism.  The  unit  for  meas- 
urement is  the  calorie,  which  signifies  the  amount  of  heat  which  is 
necessary  to  raise  one  kilogram  of  water  1°  C. 

Now,        I  gm.  of  albumin  furnishes 4. 1  calories. 

I         "     carboliydrate  furnishes 4. 1         " 

I         "     fat  "  9-3        " 

I         "     alcohol  "  7  " 

Instead  of  saying  a  man  requires  100  gm.  albumen,  100  gm.  fat, 
and  400  gm.  carbohydrates,  one  now  expresses  this  in  calories, 
thus  :    A  man  requires 

100  gm.  albumen  X     4-l> 4^°  calories. 

100  gm.  fats  X     9-3> 93°       " 

400  gm.  carbohydrates  X     4'^> 1640       " 

Total, 29S0 

4 


9 


46  PHYSIOLOGY    OF    DIGESTION. 

For  every  kilogram  of  body  weight,  an  adult  requires,  when  at 
rest,  a  food-supply  of  30  to  34  calories ;  during  light  occupation,  a 
food-supply  of  34  to  40  calories ;  during  medium  occupation,  a 
food-supply  of  40  to  45  calories;  during  hard  work,  a  food-supply 
of  45  to  60  calories. 

In  very  adipose  and  obese  persons  the  requirements  for  food  are 
less  than  the  quantities  stated  by  one-quarter  to  one-third.  If  the 
above  calculations  of  the  requisite  number  of  calories  per  kilogram 
weight  of  any  person  are  correct,  and  the  supply  maintained  accord- 
ingly, the  individual  will  maintain  his  weight.  If  the  supply  of 
calories  is  greater,  he  will  gain  weight ;  if  the  supply  is  less,  he  will 
lose  weight. 

In  a  condensed  statement  of  facts  like  the  present,  it  will  be  ex- 
pedient to  pass  over  the  physiology  of  hunger,  appetite,  and  thirst, 
which  will  be  considered  in  the  clinical  part  of  this  work  (bu- 
limia, anorexia,  etc.),  and  proceed  at  once  to  digestive  actions. 

Ptyalin  Digestion. — Digestion  really  begins  in  the  mouth, 
where  the  food  is  chewed  into  small  bits  and  mixed  with  saliva, 
which  mechanically  facilitates  mastication  and  deglutition.  Chemi- 
cal transformation  also  begins  here,  for  the  diastasic  ferment  of 
saliva,  ptyalin,  transforms  a  small  portion  of  the  starchy  foods  into 
sugar  and  maltose. 

Ptyalin  can  produce  this  transformation  of  starchy  foods  only  in 
an  alkaline  medium,  accordingly  the  action  ceases  in  the  stomach  ; 
but  not  immediatel}',  however,  as  the  conversion  of  starches  into 
sugar  goes  on  until  the  degree  of  acidity  reaches  i  :  1000.  As  the 
ptyalin  ferment  becomes  inactive  in  this  acidity,  the  question  arises, 
whether  its  activity  is  permanently  destroyed  by  an  acidity  of 
I  :  1000,  or  only  temporarily,  and  whether  it  can  resume  its  in3fe.rt- 
_ing  power  when  the  acid  is  neutralized.  Boas,  who  attempted  a 
solution  of  this,  came  to  the  conclusion  that  subsequent  alkalini- 
zation,  or  diminution  of  the  acid,  causes  the  ptyalin  to  act  again, 
so  that  in  later  stages  of  stomach  digestion,  when  the  acid  produc- 
tion ceases,  the  conversion  of  starch  into  grape  sugar  may  be 
resumed,  but  it  never  becomes  as  active  as  before. 

The  existence  of  appetite  is  to  a  degree  dependent  upon  the 
intactness  of  the  salivary  glands. 

Digestion  of  Starches. — In  order  to  understand  the  various 
stages  of  starch  conversion,  it  is  essential  to  study  the  digestion 
of  starch  by  ptyalin  in  the  clinical  laboratory.     There  are  recog- 


DIGESTION    OF    STARCHES.  47 

nized  four  stages  of  starch  conversion,  each  distinct  from  the  other, 
until  dextrose  is  reached. 

1.  (a)  This  is  common  starch,  representing  a  glue-Hke,  mucil- 
aginous jelly,  not  a  clear  solution,  giving  a  dark-blue  color  with 
iodin  and  iodid  of  potassium  solution.  The  next  stage  shows 
the  first  action  of  ptyalin. 

(d)  Amididin  or  Amy  I o  dextrin. — This  still  gives  a  distinctly  blue 
color,  though  not  so  deep  as  No.  i  («),  with  Lugol's  solution  ; 
but  amylodextrin  is  a  soluble  starch,  and  represents  a  real  solution. 

2.  {a)  Erythrodextrin. — Gradually,  as  the  inversion  progresses,  the 
color  produced  by  the  iodin  solution  becomes  violet-blue,  violet, 
red  violet,  red,  or  mahogany  brown  ;  this  modification  is  called 
erythrodextrin. 

(b)  Acliroodextrin. — With  continued  action  of  the  ptyalin,  a  sub- 
stance is  reached  which  gives  no  color  with  iodin  ;  this  is  called 
achroodextrin.  Amidulin  is  precipitated  by  tannic  acid  and 
alcohol,  but  erythrodextrin  and  achroodextrin  are  precipitated  by 
alcohol  and  ether,  not  by  tannic  acid.  These  two  dextrins  do  not 
reduce  Fehling's  solution,  and  do  not  ferment  with  yeast. 

3.  Maltose. —  Soluble  in  alcohol,  insoluble  in  ether  ;  reduces 
Fehling's  solution,  but  not  Barfoed's  reagent  (a  four  per  cent, 
solution  of  cupric  acetate  to  which  one  per  cent,  acetic  acid  is 
added);  does  not  ferment  with  yeast. 

4.  Dextrose. — Insoluble  in  alcohol  and  ether  ;  reduces  Fehling's 
as  well  as  Barfoed's  solution ;   ferments  readily  with  yeast. 

It  is  important  to  familiarize  oneself  with  these  reactions,  as  it 
often  becomes  necessary  to  determine  the  degree  of  starch  conver- 
sion in  cases  of  hyperacidity  or  supersecretion. 

It  was  formerly  thought  that  the  starch  was  first  converted 
to  dextrin,  and  this  in  turn  was  converted  to  sugar.  Accord- 
ing to  Prof  W.  H.  Howell  ("  Amer.  Textbook  of  Physiology"), 
it  is  believed  that  the  starch  molecule,  which  is  quite  complex, 
consisting  of  some  multiple  of  CyHi,,0.5, — possibh-  (Ci3Hiij05)20, — 
first  takes  up  water,  thereb}'  becomes  soluble  (soluble  starch, 
amylodextrin),  and  then  splits  with  the  formation  of  dextrin  and 
maltose,  and  that  the  dextrin  again  undergoes  the  same  hydrolytic 
process  and  may  continue  under  favorable  conditions  until  only 
maltose  is  present.  The  difficulty  at  present  is  in  isolating  the 
different  forms  of  dextrin  that  are  produced.  It  is  usually  said 
that  at  least  two  forms  occur,  one  of  which  gives  a  red  color  with 


48 


PHYSIOLOGY    OF    DIGESTION. 


iodin,  and  is  known  as  erythrodextrin,  while  the  other  gives  no 
color  reaction  with  iodin,  and  is  termed  achroodextrin.  It  is 
pretty  certain,  however,  that  there  are  several  forms  of  achroodex- 
trin, and,  according  to  some  observers,  erythrodextrin  also  is  really 
a  mixture  of  dextrins  with  maltose  in  varying  proportions.  In 
accordance  with  the  general  outline  of  the  process  given  above, 
Neumeister  proposes  the  following  schema,  which  is  useful  because 
it  gives  a  clear  representation  of  one  theory,  but  which  must  not 
be  considered  as  satisfactorily  demonstrated  : 


Starch — .Solu- 
ble   Starch. 
Amylodex- 
trin. 


r  Maltose. 


I    Erythro- 
[  dextrin. 


f  Maltose. 

I 
I 

Achroo- 
dextrin. 


f  Maltose. 

I 
Achroo- 
dextrin. 


f  Maltose. 

Achroo- 
dextrin. 

(Malto- 
dextrin.) 


f  Maltose. 


rs 


[  Maltose. 


Von  Mering  and  Ewald  have  shown  that  in  the  transformation 
of  starch  into  sugar  by  ptyalin,  the  greater  portion  is  converted  into 
maltose — only  a  small  portion  into  dextrose.  But  the  maltose 
formed  in  the  stomach  is  changed  to  dextrose  in  the  intestine.  If 
the  amylaceous  transformation  proceeds  normally  in  the  mouth 
and  stomach,  after  a  time,  within  an  hour,  at  least,  so  much  starch 
has  been  changed  into  achroodextrin,  maltose,  and  dextrose,  that 
the  addition  of  small  quantities  of  Lugol's  solution  to  the  filtered 
stomach  contents  no  longer  produce  any  changes  in  color.  The 
occurrence  of  a  purple  (erythrodextrin)  or  a  blue  color  (starch) 
shows  that  the  starch  transformation  has  been  incomplete.  Now, 
this  may  be  due  either  to  a  deficiency  of  ptyalin  or  to  a  rapidly 
increasing  acidity  or  hyperacidity  of  the  stomach. 

Ewald  states  that,  although  he  tested  a  large  number  of  patients 
for  the  fermentative  power  of  saliva,  he  never  found  a  saliva  that 
could  not  convert  starch  into  sugar.  This,  too,  when  he  tested  the 
salivary  secretion  of  patients  with  dental  caries,  angina,  diphtheria, 
and  carcinoma  of  the  tongue. 

From  the  above  it  is  evident  that  there  must  be  two  stages  of 
gastric  digestion,  (i)  an  amylolytic  and  (2)  a  proteolytic.  Having 
satisfied   ourselves   as   regards   the  fate   of  the   carbohydrates,  or 


GASTRIC    JUICE.  49 

Starches,  let  us  proceed  to  study  proteolytic  digestion,  or  con- 
version of  proteids,  albumens,  gelatins,  fibrins,  elastin,  meat,  etc.,  etc. 

Gastric  Juice. — Hydrochloric  Acid.  —  The  secretion  of  the 
stomach  is  a  complex  fluid,  clear,  colorless,  and  of  acid  reaction;  it 
has  only  one-half  per  cent,  of  solid  ingredients.  The  amount  secreted 
in  twenty-four  hours  is  about  1600  gm.  Its  chief  constituent  is 
hydrochloric  acid,  which  it  contains  in  the  amount  of  o.i  to 
0.22  per  cent,  (one  to  two  per  thousand).  This  degree  of  acidity 
is  not  reached  at  once,  but  gradually  ;  at  the  beginning  and  end  of 
stomach  digestion,  the  percentage  of  HCl  is  considerably  less. 
Besides  the  HCl,  gastric  juice  contains  two  unorganized  ferments, 
pepsin  and  rennin. 

Hydrochloric  acid  acts  in  six  different  ways,  all  of  which  are  of 
great  significance  for  the  normal  progress  of  digestion. 

1.  HCl  acts  as  an  antizymotic  or  antiseptic,  destroying  patho- 
genic organisms  and  preventing  abnormal  fermentations.  This 
antibacterial  effect  extends  even  into  the  duodenum. 

2.  HCl  has  the  power  to  convert  the  pro-enzymes  of  the  gastric 
glands  (pepsinogen  and  rennin  zymogen)  into  active  ferments  in  a 
very  short  time  (according  to  Langley,  in  one  minute). 

3.  This  gastric  acid  possesses  a  certain  regulatory  influence  on 
the  progress  of  peristalsis. 

4.  HCl  transforms,  with  the  aid  of  pepsin,  albuminous  bodies  into 
peptones,  gelatin  into  gelatin  peptone,  elastin  into  elastin  peptone. 
But  in  reality  the  pepsin  is  the  main  or  chief  agent  in  these  trans- 
formations, as  the  HCl  can  be  effectively  substituted  by  nitric, 
phosphoric,  oxalic,  sulphuric,  lactic,  and  butyric  acids. 

5.  By  HCl  cane  sugar  is  changed  to  invert  sugar  (dextrose 
and  levulose).  This  property  is  also  ascribed  to  a  number  of  bac- 
teria that  can  invert  cane  sugar,  although  after  a  longer  time. 

6.  HCl,  finally,  is  instrumental  in  bringing  into  solution  the 
soluble  calcium  and  magnesium  salts,  introduced  in  the  food. 

Concerning  the  origin  and  derivation  of  the  hydrochloric  acid, 
we  unfortunately  have  nothing  but  speculation.  No  free  acid  oc- 
curring in  the  blood  or  lymph,  it  is  rational  to  conclude  that  it  is 
produced  in  the  secreting  (oxyntic  ?)  cells  of  the  gland-ducts.  It 
seems  probable  that  the  acid  is  derived  from  the  neutral  chlorids  of 
the  blood,  which  are  in  some  way  decomposed,  the  chlorin  uniting 
with  hydrogen  to  form  HCl.  The  acid  is  secreted  at  the  gastric 
mucosa,  while  the  base  remains  behind,  and  probably  passes  back 


50  PHYSIOLOGY    OF    DIGESTION. 

into  the  blood.  This,  in  a  way,  explains  the  increased  alkalinity  of 
the  blood  and  the  decrease  of  acidity  of  the  urine  after  meals,  the 
return  of  basic  substances  into  the  circulation  naturally  having  such 
an  effect.  According  to  Heidenhain,  a  free  organic  acid  is  secreted 
by  the  cells  (oxyntic),  which  then  decomposes  the  chlorids.  Ac- 
cording to  Maly,  the  HCl  is  the  result  of  a  reaction  between  the 
phosphates  and  chlorids  of  the  blood  as  expressed  in  the  following 
two  equations  : 

XaHjPO,  +  NaCl  =  Na,HPO,  +  HCl  or 
SCaClj  +  2Na,HP0i  =  Ca3"(P0J,  +  4NaCl  -f  2HCI. 

What  is  known  thus  far  of  the  specific  action  of  living  cells,  en- 
forces the  impression  here,  that,  as  in  other  chemical  processes  not 
yet  understood,  vital  phenomena  are  difficult  to  express  in  chemical 
formulae. 


CHAPTER  V. 

PEPSINOGEN    AND    PEPSIN.— RENNIN     ZYMOGEN    AND 
RENNIN— INTESTINAL     DIGESTION- 
DUODENAL  INTUBATION. 

It  should  not  be  understood  that  all  combinations  of  the  gastric 
juice  with  albumins  are  at  once  peptones  ;  like  the  starches,  the 
proteids  reach  their  end  stage  of  gastric  digestion  by  a  series  of 
distinct  intermediate  stages.  These  are  (i)  proteid,  (2)  acid 
albumin  or  syntonin,  (3)  propeptone  or  hemi-albumose,  and  (4) 
peptone.  Besides  forming  peptones  out  of  albumins,  pepsin  deprives 
gelatin  of  its  property  to  coagulate,  or  rather  to  gelatinize,  and 
forms  gelatin  peptones  out  of  it.  Peptones  are  derived  from  egg, 
serum,  and  plant  albumins,  gelatin,  meat,  fibrin,  casein,  etc. 

The  steps  in  peptic  digestion  may  be  made  more  intelligible  by 
the  following  schema,  modified  from  that  of  Neumeister  ("  Lehr- 
buch  d.  physiol.  Chemie,"  1893,  p.  187): 

Proteid 


Syntonin, 


Primary  proteoses, Protoproteose  Heteroproteose. 

Secondary  proteoses,  .    .         .    .  Deuteroproteose  Deuteroproteose. 

Amphopeptones,      Peptone  Peptone. 

No  other  mineral  acid  gives  as  good  results  with  pepsin  as 
HCl,  which  can  form  pepsin  from  pepsinogen  in  the  quickest  time. 
It  is  useful  to  be  able  to  test  for  propeptone  formation.  In  normal 
digestion,  one  hour  after  the  test  breakfast,  propeptone  is  present 
only  in  traces,  or  usually  is  not  to  be  detected  at  all ;  but  in  abnor- 
mally slow  digestion  it  is  still  abundant  at  that  period. 

The  best  method,  up  to  present  date,  is  by  means  of  the  biuret 

51 


52  PEPSIXOGEN    AND    PEPSIN. 

reaction.  In  this  reaction  a  dilute  solution  of  cupric  sulphate  is 
added  to  stomach  contents  in  the  cold,  and  a  few  drops  of  potassium 
hydroxid  added  sufficient  to  make  the  solution  alkaline ;  an  intense 
red  color  results.  Cupric  sulphate  and  KOH,  added  to  ordinary 
albumin  and  syntonin,  without  warming,  produces  a  bluish  violet, 
which  must  be  distinguished  from  the  purple-red  of  biuret. 

The  more  marked  the  propeptone  reactions  are,  the  less  the  pep- 
tone which  has  been  formed  and  eventually  removed  from  the 
stomach.  We  can  approximately  estimate  the  amount  of  the  pep- 
tone by  the  intensity  of  the  biuret  reaction  if  we  always  use  the 
same  quantities  of  stomach  contents,  caustic  potash,  and  cupric  sul- 
phate, and  compare  it  with  the  reaction  given  with  a  peptone  solu- 
tion of  known  strength.  Peptone  gives  the  same  pink,  purple-red 
color  with  the  biuret  reaction  as  propeptone.  If  we  desire  to 
estimate  the  rate  of  proteolysis  in  the  stomach,  the  biuret  reaction 
will  not  permit  us  to  distinguish  between  these  two  bodies  ;  the  only 
differentiation  possible  is  by  precipitation  of  the  propeptone  in  the 
following  manner:  The  stomach  filtrate  is  carefully  neutralized, 
an  equal  quantity  of  common  salt  solution  is  added,  and  then  a  few 
drops  of  concentrated  acetic  acid.  A  precipitate  will  be  propep- 
tone, which  can  be  filtered  off  and  weighed  ;  any  red  biuret  reaction 
after  this  separation  must  be  due  to  peptone. 

In  order  to  determine,  in  a  given  specimen  of  stomach  contents, 
whether  the  pepsin  or  HCl  is  present  in  too  great  or  too  small  a 
quantity,  one  proceeds  in  the  following  manner: 

Pour  lo  c.c.  filtered  stomach  contents  into  four  test-tubes  and 
number  them  Nos.  i,  2,  3,  4.  To  No.  i,  nothing  further  is  added  ;  to 
Xo.  2,  enough  HCl  to  make  a  solution  of  three  to  five  per  thousand 
(this  can  be  accomplished  by  adding  one  to  two  drops  of  officinal 
HCl,  U.  S.  Pharm.,  to  10  c.c.  filtrate);  to  No.  3,  0.2  to  0.5  gm.  (gr. 
iij  to  gr.  vij)  of  pure  pepsin  is  added,  and  to  No.  4  both  HCl  and 
pepsin  are  supplied. 

A  small  disc  of  egg  albumen  (which  is  prepared  by  cutting 
boiled  egg  albumen  into  lamellse  of  uniform  thickness  with  a 
microtome  and  punching  out  equal  circles  by  a  cork  borer)  is 
added  to  each  test-tube,  and  they  are  then  put  in  the  incubator 
at  100°.  The  rate  at  which  the  albumin  is  dissolved  will  tell  us 
whether  the  filtrate  was  perfect  in  the  requisite  amount  of  pepsin 
and  HCl,  whether  pepsin  alone,  or  HCl  only,  or,  finally,  whether 
both  were  necessarv.     In  this  wav  we  can  discover  which  factor  is 


RENNIN.  5  3 

at  fault.  In  the  human  stomach  the  formation  of  peptone  remains 
at  a  certain  percentage  by  the  removal  or  absorption  of  peptones 
over  that  amount,  and  also  it  would  seem  by  an  inhibiting  influence 
which  a  certain  percentage  of  peptone  has  over  the  proteolytic  pro- 
cess in  retarding  or  suspending  it.  As  this  can  not  be  imitated  in 
a  test-tube,  i.  e.,  the  absorption  of  ready  formed  peptones,  a  seem- 
ingly delayed  digestive  process  of  egg-albumen  discs  in  the  test- 
tubes  may  in  reality  be  due  to  a  very  active  stomach  filtrate. 

Rennin,  the  second  gastric  ferment,  produces  a  light,  not  Y&ry 
cohesive,  coagulation  of  milk.  This  coagulation  is  a  charac- 
teristic cake  of  casein  floating  in  clear  serum,  more  dense,  not 
lumpy,  more  cohesive  coagulation,  than  produced  by  acids.  This 
ferment  is  a  constant  constituent  of  the  stomach  contents,  just  as 
pepsin  and  pepsinogen.  With  a  complete  absence  of  the  rennin 
and  its  pro-enzyme,  one  can  with  certainty  conclude  that  the  case 
is  one  of  atrophy  of  the  gastric  mucosa. 

The  demonstration  of  rennin  ferment  is  carried  out  in  the  fol- 
lowing manner :  Ten  c.c.  of  raw,  unboiled  milk  are  placed  in  the 
incubator  with  2.5  drops  of  stomach  filtrate.  If  rennin  is  present, 
the  characteristic  milk  coagulation  will  occur  in  a  variable  time 
(one  minute  to  several  hours,  according  to  the  quantity  of  ferment). 

Occasionally,  rennin,  the  perfect  ferment,  is  not  contained  in  the 
stomach  contents,  while  at  the  same  time  rennin  zymogen  is  pres- 
ent. This  is  demonstrated,  according  to  Hammarsten,  by  adding  to 
the  mixture  just  described  two  c.c.  of  a  concentrated  solution  of 
calcium  chlorid,  CaCl2. 

If  a  rennin  coagulum  occurs,  it  follows  that  rennin  zymogen  is 
present,  but  not  the  perfect  ferment.  For  these  tests,  raw  milk 
only  can  be  used,  as  it  coagulates  ten  times  as  rapidly  as  boiled 
milk.  Jaworski  has  pointed  out  that  in  cases  where  tests  for  rennin 
and  rennin  zymogen  are  both  negative,  it  is  advisable  to  try  pour- 
ing a  0.3  per  cent,  to  0.6  per  cent,  solution  of  hydrochloric  acid 
into  the  stomach,  to  see  whether  this  HCl  may  not  be  able  to 
awaken  a  secretion  of  rennin;  this  should  especially  be  done  before 
making  the  diagnosis  of  complete  atrophy  of  the  mucosa. 

The  Physiology  of  Intestinal  Digestion. — Our  knowledge  of 
the  digestive  processes  in  the  intestine  is,  from  a  physiological  as 
well  as  from  a  pathological  point  of  view,  defective,  at  times  con- 
tradictory.     Concerning  gastric  digestion,  we   are    much  better  in- 


54 


INTESTINAL    DIGESTION. 


structed,  because  here  the  processes  are  simpler,  and  material  for 
investigation  can  be  more  easily  obtained.  The  stomach-tube 
supplies  us  without  dijfficulty  with  gastric  contents,  but  hitherto  all 
intestinal  contents  of  human  beings  have  been  obtained  from  rare 
cases  of  intestinal  fistulae,  for  the  feces  give  no  constant  and  re- 
liable information  of  the  digestive  actions  in  the  smaller  intestine. 

The  earliest  investigations  of  intestinal  contents  were  made  in 
1662  by  Regnier  de  Graaf,  who  made  experimental  fistulae  into  the 


Fig.  5. — Apparatus  for  Obtaining  Intestinal  Contents. 


intestinal  canal  of  animals.  It  is  a  curious  historical  fact  that  this 
intestinal  experiment  antedated  the  first  investigations  of  stomach 
contents  which  were  carried  on  in  1752  by  Reaumur.  So  up  to 
the  present  time  there  was  no  prospect  of  getting  a  better  insight 
into  the  physiology  of  intestinal  digestion  until  a  method  for  intu- 
bating the  duodenum  in  the  living  human  subject  was  devised  by 
the  author. 

This  method,  which  is  described  in  the  Johns  Hopkins  Hospital 
Medical  Bulletin  for  April,  1895,  and  also  in  "Boas'  Archiv.  for 


PHYSIOLOGY    OF    INTESTINAL    DIGESTION. 


55 


Digestive  Diseases,"  vol.  ii,  page  85,  consists,  in  the  first  place,  of 
the  introduction  of  a  thin,  elastic  rubber  bag  into  the  stomach.  This 
bag,  when  folded  over  a  tube  which  runs  through  it,  does  not 
occupy  as  much  space  as  an  ordinary  stomach-tube,  and  has 
the  exact  shape  of  the  human  stomach  when  it  is  distended  by 
blowing  it  up  within  that  organ,  to  which  it  fits  itself  exactly, — and 
is  closely  applied  to  the  gastric  walls. 

The  intragastric  bag  is  distended  by  the  pressure  apparatus 
shown  in  figure  6.  The  graduated  bottle  (A)  is  full  of  water  and 
elevated  above  the  bottle  (B),  which  is  empty  and  also  graduated. 


Fig.  6. — Pressure  Bottles  for  Distending  the  Intragastric  Bag  during  Duodenal 

Intubation. 


The  stomach-shaped  bag  (C),  when  it  reaches  the  stomach,  is 
connected  with  the  lower  empty  bottle  (B).  Then  the  stop-cock 
permitting  the  water  to  run  from  ^  to  ^  is  opened,  and  the  water 
runs  from  A  into  B,  displacing  the  air  in  B,  which  distends  the  bag, 
C,  within  the  stomach,  filling  it  entirely.  As  is  observable  on  this 
bag,  a  guide  is  contained  in  it,  running  along  the  dotted  line  par- 
allel to  the  lesser  curvature.  In  this  guide  the  duodenal  tube  is 
inserted,  lubricated   with    oil   before   the   bag  is   pushed  into   the 


56  DUODENAL    INTUBATION. 

stomach.  This  tube  is  provided  with  very  thick  walls,  by  virtue  of 
which  it  is  not  easily  kinked  or  bent  upon  itself. 

The  relation  of  the  thickness  of  the  walls  to  the  diameter  of  the 
lumen  is  shown  in  the  cross-section  of  figure  5.  When  the  intra- 
gastric bag  is  blown  up,  it  fills  the  stomach  entirely.  The  duo- 
denal tube  lies  in  its  sheath  or  guide,  and,  on  being  pushed  onward 
from  the  mouth,  it  is  not  possible  for  it  to  go  an^-where  else  except 
through  the  pylorus  into  the  duodenum.  In  the  figures  it  can  be 
seen  that  the  bag  is  not  distended  by  the  duodenal  tube,  but  a 
separate,  very  small  tube  runs  down  the  esophagus,  ending  in  the 
bag,  serving  the  purpose  of  its  distention.  Both  tubes  together  do 
not  occupy  as  much  space  as  an  ordinary  stomach-tube. 

A  description  of  this  method  is  considered  essential  because  it 
seems  to  be  destined  to  bring  our  knowledge  of  the  physiology  and 
pathology  of  the  intestines  upon  a  basis  of  ascertained  facts ; 
because  we  can  at  any  time  thereby  obtain  the  contents  of  the 
intestine,  and  the  gut  may  in  any  of  its  parts  be  reached  with  safety. 

After  known  test  meals,  it  is  possible,  after  they  have  passed  from 
the  stomach  into  the  duodenum,  to  draw  out  samples,  from  this 
part  and  subject  them  to  analysis.  By  alternately  distending  any 
part  with  air  or  water  we  will  be  enabled  to  locate  the  part  by  the 
percussion  sound  on  the  outside  of  the  abdomen,  and  the  distance 
it  is  located  from  the  mouth  can  be  seen  from  the  length  of  tube 
introduced. 

Small  electric  lamps  may  be  introduced  into  the  duodenum  as 
they  are  into  the  stomach,  and  the  location  and  condition  recog- 
nized by  electrodiaphany. 

Hitherto,  in  all  experiments  on  this  subject  it  has  been  impossible 
to  obtain  either  the  pancreatic  or  biliary  secretion  in  a  pure  con- 
dition ;  this  is  due  to  the  fact  that  both  the  pancreatic  and  the 
common  gall-duct  empty  into  the  descending  portion  of  the  duo- 
denum very  near  each  other. 

Just  at  present  we  have  under  observation  a  female  patient  who 
has  suffered  repeated  biliary  colic.  At  times  she  passes  small 
stones  without  giving  her  much  pain, — at  least,  they  are  found  in 
the  stools  without  having  given  her  any  colic.  She  is  willing  to 
undergo  an  operation  to  be  relieved.  Through  the  comparatively 
thin  abdominal  walls  we  are  able  to  feel  numerous  stones  in  the 
gall-bladder.  She  consented  to  an  attempt  at  intubation  of  the 
duodenum  to  determine  whether  there  was  any  bile  secreted.     The 


THE    PANCREAS.  57 

duodenum  was  entered  without  difficulty,  and  cleansed  by  running 
in  and  aspirating  out  distilled  warm  water.  Twenty-four  hours 
afterward  the  duodenum  was  again  intubated  according  to  our 
method,  and  washed  with  lOO  c.c.  of  warm  distilled  water. 

On  being  aspirated,  this  water  was  still  clear,  but  viscid  and 
sticky,  similar  to  a  solution  of  egg-albumen.  It  contained  no 
bile  pigments  nor  cholesterin,  and  was  free  from  taurocholates  and 
glycocholates.  It  was  colorless  and  odorless,  and  seemed  very  rich 
in  some  form  of  albumin.  That  it  was  pure  pancreatic  juice  was 
proven  by  its  digesting  fibrin  and  serum  albumin. 

The  juice  obtained  in  this  manner  will  digest  from  85  to  95  per 
cent,  of  Merck's  dried  serum  albumin  in  the  digestorium  at  100°  F. 
in  two  hours.  The  amylolytic  and  fat-decomposing  property  of  the 
juice  was  determined  in  a  similar  manner.  One  is  therefore  justi- 
fied in  concluding  that  in  this  case  the  pancreatic  juice  was  obtained 
almost  pure,  as  there  were  no  bile  elements  contained  in  it,  the 
bile  being  prevented  from  entering  the  duodenum  by  a  calculus  or 
catarrhal  occlusion  in  the  common  duct.  As  there  are  also  pan- 
creatic calculi,  or  occlusions  of  the  duct  by  neoplasm  or  catarrhal 
swelling,  it  is  conceivable  that  we  may  yet  be  able  to  obtain  the 
bile  in  a  pure  condition,  and  free  from  pancreatic  juice,  in  the 
human  subject. 

The  secretion  of  Brunner's  and  Lieberkiihn's  glands  will,  how- 
ever, always  constitute  an  admixture  of  these  juices. 

The  Pancreas  ;  its  Secretion  and  Pancreatic  Digestion. — 
In  1846  Claude  Bernard  made  the  first  scientific  and  fundamental 
investigation  concerning  the  pancreatic  secretion.  Later  on, 
Kiihne,  Bidder  and  Schmidt,  Corvisart,  Heidenhain,  and  others 
enlarged  these  results. 

Its  secretion,  as  Bernard  first  observed,  is  dependent  upon 
digestion,  and  is  a  clear,  colorless,  and  odorless  fluid,  very  alkaline, 
and  so  rich  in  albumin  that  it  solidifies  on  boiling.  Zawardsky  had 
opportunity  of  analyzing  the  normal  human  pancreatic  secretion 
in  a  case  of  pancreatic  fistula,  which  remained  behind  after  removal 
of  a  tumor.  According  to  his  analysis  it  contained  86.4  per 
cent,  water,  13.25  organic  substances;  among  the  latter  are  9.2 
proteid  bodies  and  0.83  extractive  substances,  soluble  in  alcohol ; 
lastly,  0.34  per  cent,  salts. 

The  chyme  which  passes  into  the  duodenum  from  the  stomach 
comes  under  the  influence  of  formed  or  organized  and  unformed 
or  unorganized  ferments.     The  formed  or  organized  ferments  are 


58  THE    PANCREAS. 

represented  by  bacteria,  which  bring  about  carbohydrate  fermenta- 
tion, mostly  in  upper  bowel,  and  proteid  putrefaction,  mostly  in 
lower  bowel. 

The  unorganized  ferments  are  contained  in  the  pancreatic  secre- 
tion, the  bile,  and  in  the  succus  entericus.  The  most  important 
constituents  of  the  pancreas  are  three  ferments  or  enzymes:  (i) 
an  amylolytic,  (2)  a  proteolytic,  and  (3)  a  fat-splitting  ferment. 

According  to  W.  G.  Halliburton  and  T.  G.  Burton  {^Journal  of 
Physiology,  vol.  xx,  p.  106),  pancreatic  juice  possesses  a  milk-pre- 
cipitating substance,  causing  at  35°  to  45°  C.  a  granular  precipitate 
in  milk,  but  there  is  no  solidification  until  the  milk  cools,  when  it 
sets  to  a  coherent  curd.  On  warming,  the  curd  is  broken  up,  and 
the  milk  resumes  its  granular  fluidity.  The  granular  precipitate 
produced  by  pancreatic  juice  seems,  according  to  these  observers, 
to  be  intermediate  between  casein  and  caseinogen. 

The  amylolytic  or  pancreas  diastase  is  very  similar  to  ptyalin  in 
its  action,  and  changes  boiled  starch  into  maltose  exceedingly 
rapidly  at  body  temperature.  In  addition,  small  quantities  of  dex- 
trin and  grape  sugar  are  formed  ;  one  gm.  of  pancreatic  juice  from 
a  dog  will  invert  3.6  gm.  starch  into  sugar.  Cane  sugar  and  inuHn 
are  not  affected  by  it.  According  to  Zweifel,  this  ferment  is  absent 
in  the  pancreas  of  new-born  children. 

The  fat-splitting  ferment  of  the  pancreas  (also  called  steapsin), 
which  thus  far  has  not  been  obtained  in  a  pure  state,  breaks  up 
neutral  fats  into  fatty  acids  and  glycerin.  This  process  occurs 
very  slowly,  however.  Berthelot  found  that  15  gm.  of  pancreatic 
secretion  of  the  dog  required  at  least  twenty-four  hours  to  break 
up  two  decigrams  of  monobutyrin  completely  into  butyric  acid  and 
glycerin.  The  fatty  acids  formed  during  this  transformation  com- 
bine with  alkalies  in  the  intestine  to  form  soaps,  which  by  emulsi- 
fying other  fats  assist  greatly  in  their  absorption.  In  the  labo- 
ratory it  always  requires  powerful  mechanical  action  to  effect  an 
emulsion  of  fats  ;  not  so  in  the  intestine,  where  it  is  evidently  accom- 
plished with  great  facility.  That  this  must  greatly  assist  in  fat 
resorption  is  evident  from  the  frequent  observation  that  after 
disease  of  the  pancreas  the  feces  become  very  rich  in  fat,  which 
may  be  present  in  such  a  large  amount  as  to  congeal  on  the  sur- 
face of  the  stool. 

The  proteolytic  ferment  of  the  pancreas  has  been  called  trypsin 
by  Kiihne.  Using  pancreatic  juice  and  boiled  blood-fibrin,  he 
found  that  it  did  not  swell  up,  but  that  it  became  very  fragile,  and 


THE    PANCREAS.  59 

finally  liquefied.  As  we  take  in  all  of  our  albumin  in  a  boiled  or 
roasted  state,  which  becomes  peptone  in  the  stomach  and  not  solu- 
ble albumin,  the  question  has  arisen — whither  do  we  derive  our 
soluble  native  albumin  ?  This  is  obtained  from  pancreatic  trypsin 
digestion  of  boiled  albuminous  bodies,  which  changes  them  to 
albumin  soluble  in  water,  or  at  least  in  a  weak  saline  solution,  from 
which  they  can  be  precipitated  by  heat.  The  proteolytic  action  of 
trypsin  takes  place  in  an  alkaline  or  neutral  medium  only. 

Among  the  bodies  formed  from  albumins  and  proteids  under  the 
influence  of  trypsin  are  a  globulin  that  is  insoluble  in  water,  hemi- 
peptone  and  antipeptone,leucin,tyrosin,  and  asparaginic  acid.  Indol, 
which  is  found  in  the  jejunum,  is  a  product  of  bacterial  action  on 
albumins.  A  chromogenic  body  has  been  described  by  Tiedemann 
and  Gmelin  which  has  received  the  name  tryptophan  ;  it  is  a  result 
of  advanced  albumin  decomposition.  Trypsin,  then,  to  sum  up, 
changes  proteids  to  peptones  and  soluble  albumins,  casein  to 
casein  peptones,  gelatin  to  gelatoses  and  gelatin  peptone,  and  elastin 
to  elastoses  and  elastin  peptones. 

In  animals  that  have  been  deprived  of  their  pancreas  by  opera- 
tion only  44  per  cent,  of  proteid,  57  per  cent,  to  70  per  cent,  of 
carbohydrates,  and  no  fats  at  all,  were  absorbed,  although  four- 
fifths  of  the  fats  were  split  up  into  fatty  acid  and  glycerin. 

The  processes  of  tryptic  digestion  are  briefly  represented  in  the 
following  schema,  according  to  Neumeister : 

Proteid 


Deut  ero albumose 


Amphopeptone 


Antipeptone  Hemipeptone 


Leucin  Tyrosin  Aspartic  acid  Tryptophan 

Trypsin  produces  peptone  from  proteids  more  readily  than  does 
pepsin. 


CHAPTER  VI. 

THE  BILE.— THE     SUCCUS  ENTERICUS.— INTESTINAL 

FERMENTATION.— PUTREFACTION.— FORMED 

OR  ORGANIZED  FERMENTS. 

It  is  known  at  present  that  the  bile  exerts  no  chemical  effects 
upon  the  food-materials  ;  nevertheless  its  presence  in  the  duodenal 
chyme  is  significant  on  account  of  its  alkaline  reaction  and  its 
effect  on  the  mucous  membrane.  The  most  important  function  of 
the  bile  is  the  excretion  of  metabolic  products  that  can  not  be 
utilized  in  the  organism. 

The  contents  of  the  gall-bladder  represent  a  concentrated  secre- 
tion, therefore  our  knowledge  of  the  physiological  action  of  the  bile 
depends  upon  the  discharge  of  biliary  fistul^e.  The  bile  is  a  golden 
yellow,  at  times  olive-brown,  secretion  ;  it  is  never  of  a  green  color, 
but  generally  very  mucoid  and  stringy.  Its  alkaline  reaction  is 
due  mainly  to  carbonates  and  phosphates.  The  quantity  poured 
into  the  intestine  is  largest  in  the  first  hour  after  food  is  taken. 

Albumins  increase,  fats  diminish,  this  quantity,  while  sugar  and 
carbohydrates  appear  to  exert  no  influence  (Voit).  The  quantity 
secreted  in  twenty-four  hours  averages  from  500  to  600  c.c. 
(Ranke,  \\"ittich,  Hammarsten).  The  quantitative  analyses  of 
Hammarsten  have  given  the  following  results  : 

Solid  materials, ...  1. 62  to  3.52 

Water, 96.47  "  98.37 

Mucin  and  coloring-matter, 0.27  "  0.91 

Compounds  of  bile  acids  and  alkalies, 0.26  "  1. 82 

Taurocholate, 0.052  "  0.203 

Glycocholate, 0.204  "  l.t>i 

Fatty  acids, 0.024  "  0.136 

Cholesterin, 0.048  "  0.160 

Lecithin, • 0.048  "  0.065 

Fat, 0.061  "  0.095 

Soluble  salts, 0.676  "  0.887 

Insoluble  salts, 0.020  "  0.049 

At  times  a  diastatic  ferment  is  present  in  the  bile,  but  it  is  not  a 
specific  constituent  (Neumeister),  but  appears  in  the  bile  like  the 

60 


BILE    AND    THE    SUCCUS    ENTERICUS.  6l 

diastatic  ferment  which  appears  in  the  urine;  it  seems  to  be  identi- 
cal with  the  ptyalin  zymogen  of  the  pancreatic  juice. 

When  the  bile  is  prevented  from  entering  the  intestine  at  all, 
albumins,  gelatins,  and  carbohydrates  are  absorbed  in  a  normal 
manner  (Voit  and  J.  Munk),  but  the  digestion  of  fats  is  very 
seriously  interfered  with  ;  a  normal  animal  resorbs  99  per  cent,  of 
fats,  if  not  more  than  150  to  200  gr.  are  given,  i.  e.,  only  one  per 
cent,  appears  in  the  feces,  but  on  producing  an  experimental  fistula 
conducting  the  bile  outward,  60  per  cent,  of  the  fats  are  not  util- 
ized (Voit).  The  subjoined  is  a  synopsis  of  the  uses  and  func- 
tions of  the  bile  : 

1.  Fats  are  brought  into  a  fine,  permanent  emulsion  by  bile,  just 
as  by  pancreatic  juice. 

2.  Bile  assists  the  fat-splitting  effect  of  pancreatic  juice  (Nencki). 
Without  bile,  only  61  per  cent,  of  tribenzoicin  were  decomposed  by 
pancreatic  juice;  with  bile,  the  total  amount. 

3.  By  its  alkalinity  it  necessitates  the  formation  of  soaps. 

4.  Bile  dissolves  fats  in  minute  quantities. 

5.  Bile  dissolves  the  saponified  alkaline  bases  which  are  insolu- 
ble in  the  juices  of  the  intestines. 

6.  Animal  membranes  moistened  with  bile  are  more  permeable 
to  emulsified  fats  than  membranes  moistened  with  water  (von 
Wisting,  Heidenhain). 

7.  Bile  is  a  stimulant  to  the  intestinal  epithelial  cells,  incites  their 
proper  functioning  and  maintains  it  (Rohmann). 

8.  It  is  claimed  that  albuminous  bodies  and  pepsin,  dissolved  in 
the  chyme,  are  precipitated  as  a  resinous,  sticky  deposit,  which 
adheres  better  to  the  duodenal  wall,  and  effects  a  better  utilization 
of  the  albuminates  thereby. 

9.  An  inhibitory  influence  over  putrefaction  is  ascribed  to  bile 
(Maly  and  Emmerich). 

10.  An  influence  favoring  an  increase  of  the  peristalsis  of  the 
intestine  (Rohmann). 

The  Succus  Entericus. — The  succus  entericus  is  a  secretion  of 
the  crypts  of  Lieberkiihn,  and  was  first  studied  in  man  by  Demant 
after  a  herniotomy.  This  secretion  has  the  color  of  light  Rhine 
wine,  and  is  very  strongly  alkaline,  owing  to  the  presence  of  1.5 
per  cent,  carbonate  of  sodium.  The  principal  constituents  are 
albumins  and  mucin.  It  contains  also  ptyalin  and  an  inverting 
ferment,  but  has  no  effect  on  albumins  and  fats;  its  purpose  seems 
5 


62  THE  FORMED,  OR  ORGANIZED,  FERMENTS. 

to  be  probably  that  of  a  neutralizer  of  the  acids  originating  from 
fermentation  of  carbohj'drates  ;  its  excess  of  mucin  may  be  instru- 
mental for  the  onward  movement  of  the  bowel  contents. 

The  Formed,  or  Organized,  Ferments  (Bacteria). — Proteids, 
carbohydrates,  and  fats  are  subject  to  decomposition  in  the  intes- 
tines by  bacteria.  Fats  are  not  decomposed  to  any  considerable 
extent  in  the  lower  intestinal  sections  (Nencki  and  Blank),  but  a 
small  fraction  is  split  up  into  glycerin  and  fatty  acids. 

A  greater  interest  attaches  itself  to  the  fermentation  of  carbo- 
hydrates, which  occurs  principally  in  the  upper  small  intestine 
and  leads  to  the  formation  of  acetic,  lactic,  butyric,  and  carbonic 
acids,  alcohols,  and  hydrogen.  It  is  not  known  how  much  of  the 
carbohydrates  is  decomposed  in  this  manner. 

The  putrefaction  of  proteids,  caused  by  certain  bacteria  of  the 
lower  bowel,  only  occurs  in  an  alkaline  medium.  The  first  products 
of  this  putrefaction  are  the  identical  bodies  which  are  formed  dur- 
ing pancreatic  digestion,  viz. :  albumoses,  peptone,  amido-acids,  and 
ammonia.  But  then  the  putrefaction  goes  still  further;  tyrosin  is 
formed,  and  from  this,  through  a  series  of  complex  oxyacids,  the 
product  phenol  (carbolic  acid)  is  reached,  which  may  yield  phenyl- 
propionic  and  phenylacetic  acids.  A  second  variety  of  aromatic 
substances,  not  derived  from  tyrosin,  is  represented  by  indol,  skatol, 
and  skatol  carbonic  acid  ;  finally,  leucin  and  ammonia  salts  of  ca- 
pronic,  valerianic,  and  butyric  acids.  The  gases  formed  are  car- 
bonic acid  gas,  hydrogen,  hydrogen  sulphid,and  methyl-mercaptan. 
As  bacteria  can  produce  peptone,  it  might  be  presumed  that  such 
product  may  be  useful  to  the  organism.  This  peptone  is  not  made 
for  philanthropic  purposes, — it  is  simply  one  intermediate,  probably 
unavoidable,  stage  in  a  long  chain  of  decompositions. 

We  can  not  measure  the  intensity  of  carbohydrate  fermentation, 
but  the  aromatic  end-products  of  proteid  putrefaction  can  be 
approximately  estimated  by  determination  of  the  combined  and 
ethereal  sulphates  occurring  in  the  urine. 

The  number  of  bacteria  increases  from  the  duodenum  on  down- 
ward until  they  become  enormously  prolific  in  the  colon.  They 
also  differ  qualitatively.  In  the  small  intestine,  Gessner  found  a 
prevalence  of  the  bacterium  lactis  aerogenes  and  streptococcus 
pyogenes ;  the  colon-bacillus  was  present,  but  insignificant  in  num- 
bers. In  the  colon,  however,  the  reverse  was  the  case.  It  was 
formerly  an  accepted  view,  principally  defended  by   Pasteur,  that 


BACTERIA    NOT    ESSENTIAL    TO    DIGESTION.  63 

the  intestinal  bacteria  were  absolutely  indispensable  for  digestion, 
and,  therefore,  for  the  nutrition  of  the  individual.  From  this  view 
we  have  returned  to  what  seems  a  more  logical  belief,  based  on 
observations  of  Escherich,  who  held  that  bacteria  contributed  very 
little  to  the  digestion  of  the  infant,  as  they  do  not  affect  casein  and 
fats,  but  only  sugar  of  milk,  turning  it  into  lactic  and  carbonic 
acids  and  hydrogen.  The  work  of  Nuttal  and  Thierfelder  shows 
that  guinea-pigs  can  live  on  absolutely  sterile  food. 

Macfadyen,  Nencki,  and  Sieber  arrived  at  a  similar  conclusion 
in  their  now  classical  observations  on  adults.  [Arcliiv  f.  exp. 
Pathologie,  Bd.  xxviii,  1891.)  One  of  their  objects  of  study  was 
a  female  with  a  fistula  that  opened  the  small  intestine  on  the  exter- 
nal abdominal  wall,  just  at  the  end  of  the  ileum.  The  entire  colon 
was  therefore  excluded  from  the  digestive  act.  As  nearly  all  pro- 
teid  putrefaction  occurs  in  the  colon,  this  case  presented  a  chance 
to  study  the  absence  of  products  of  albuminous  putrefaction  and 
its  effects. 

It  was  found  that  bacteria  are  not  at  all  essential  to  digestion, 
as  their  patient  was  very  healthy  without  proteid  putrefaction. 
They  declare  that  the  bacterial  fermentation  of  carbohydrates  in 
the  small  bowel  is  detrimental,  rather  than  advantageous  ;  inasmuch 
as  the  bacteria  live  at  the  expense  of  the  ingested  carbohydrates, 
therefore  a  corresponding  amount  of  food  is   lost  to  the  organism. 

Our  knowledge  of  the  bacterial  activity  in  the  intestines,  though 
much  enriched  by  valuable  researches  in  the  last  decad,  is,  accord- 
ing to  our  opinion,  in  its  infancy.  So,  also,  our  knowledge  of  the 
pathogenic  significance  of  intestinal  bacteria.  There  is,  undoubt- 
edly, a  kind  of  interaction  and  correlation  between  digestive 
ferments  and  juices  on  the  one  hand,  and  bacteria  on  the  other,  or 
even  between  bacteria  and  bacteria,  or  between  the  products  of 
bacterial  metabolism.  For  instance,  Metschnikoff  has  demonstrated 
that  the  multiplication  of  the  cholera  vibrio  is  much  advanced  by 
the  presence  of  torulae  and  sarcinse  in  the  intestines. 

It  is  conceivable  that  bacteria  wage  war  upon  each  other,  as  well 
as  upon  the  cells  of  our  tissue,  and  that  we  are  benefited  by  this 
mutual  self-destruction  of  our  parasitic  inhabitants.  It  is  con- 
ceivable, also,  that  they  fall  a  prey  to  the  poisonous  metabolic 
products  of  their  own  or  other  species  of  bacteria.  Certain  very 
decomposable  food,  as  cheese  that  was  rich  in  germs,  has  been 
found  by  competent  observers  to  reduce  the    amount  of  indican 


64  HYDROCHLORIC    ACID    NOT    ABSOLUTELY    ANTISEPTIC. 

and  of  the  ethereal  sulphates  in  the  urine,  which  indicates  a  reduced 
putrefaction. 

The  human  stomach  must  not  be  regarded  as  an  organ  that  can 
absolutely  sterilize  all  food.  The  spores,  being  more  resistant  to 
HCl  than  the  fully  developed  bacteria  themselves,  pass  through 
the  stomach  uninjured.  Miller  assumes  that  at  the  height  of 
digestion  only,  when  the  amount  of  HCl  is  greatest,  the  less 
resistant  bacteria  are  killed.  Bunge,  some  years  ago,  announced 
that  the  principal  object  of  the  HCl  was  one  of  sterilization.  It  is 
undeniable,  from  recent  investigations,  that  the  human  stomach  is 
at  no  time  free  from  germs.  Captain  and  Morau  found  them  at  the 
height  of  digestion.  Abelous  found  them  in  his  own  stomach 
when  it  was  perfectly  empty.  Miller  (University  of  Berlin)  demon- 
strated that  the  mouth  contains  large  quantities  of  microbes  ;  in  one 
unclean  individual  he  estimated  the  numbers  of  mouth  bacteria  at 
1,140,000,000.  Of  25  different  varieties  occurring  in  the  mouth, 
this  observer  was  able  to  demonstrate  12  of  the  same  in  the  feces. 
Nevertheless,  the  mouth  bacteria,  according  to  Lucksdorff,  con- 
stitute only  three  per  cent.,  while  those  entering  through  the  food 
constitute  97  per  cent.,  of  the  bacteria  of  the  intestine.  There  is  no 
autochthonous  vegetation  of  bacteria  in  the  intestine ;  they  are  all 
introduced  from  the  mouth,  or  in  the  food,  or  reach  there  by  way 
of  the  circulation.  (By  autochthonous  bacteria  are  meant  such 
as  are  originally  developed  at  the  place  where  they  are  found.) 

From  observations  made  up  to  the  present  time  it  seems  prob- 
able that  catarrhal  and  other  inflammatory  diseases  of  the  intestinal 
mucosa  are  not  produced  by  specific,  constantly  recurring  microbes, 
but  that  many  kinds  of  bacteria  are  capable  of  producing  these 
diseases  under  conditions  which  are  thus  far  not  perfectly  under- 
stood. 

It  appears,  furthermore,  that  the  same  bacterium  may  at  one 
time  be  perfectly  harmless,  or  it  may  cause  a  light,  trivial  affection, 
or,  thirdly,  at  other  times  a  very  serious  disturbance.  This  is  the 
case  with  the  bacterium  coli  communis,  which  is  tolerated  without 
detriment  by  the  majority  of  mankind;  but  occasionally  it  is 
demonstrated  as  the  producer  of  colitis,  dysentery,  and  cholera 
nostras. 

The  manifold  forms  of  the  catarrhal  inflammations  are  explicable 
by  the  fact  that  the  intestinal  flora  is  also  very  manifold.  These 
same  bacteria  are  factors  in  the  etiology  of  diseases  of  the  perito- 


INTESTINAL    AUTO-INTOXlCATlON.  65 

neum,  and  of  all  organs  that  are  in  connection  with  the  intestines. 
Even  remote  organs,  not  in  anatomical  connection  with  the  bowel, 
are  not  safe  from  their  invasion. 

They  are  known  to  gain  entrance  into  the  blood  and  lymphatic 
channels  through  losses  of  substance  in  the  intestinal  mucosa.  The 
experiments  of  Posner  and  Lewin  have  taught  us  that  even  without 
such  portals  of  entry  they  seem  to  be  able  to  pass  through  the 
bowel-wall  in  masses,  and  threaten  the  organism.  Hans  Hensen 
{Zeitschr.  f.  Biol.,  Bd.  xxxv,  page  no)  has  shown  that  bacteria  can 
penetrate  natural  and  artificial  membranes,  allowing  diffusion. 
There  are  fine  canals,  passable  for  bacteria,  that  can  not  be  demon- 
strated by  the  hemoglobin  test.  Great  harm  can  be  done  to  the 
general  organism,  and  to  special  organs  in  particular,  not  only  from 
this  invasion,  but  also  from  absorption  of  the  soluble  products  of 
bacterial  metabolism  and  of  food  decomposition. 

This  condition  of  self-poisoning  from  toxic  substances  in  the 
individual's  own  intestinal  canal,  is  spoken  of  as  intestinal  auto- 
intoxication. Not  all  auto-intoxications  are  of  intestinal  origin  ; 
diabetes  mellitus,  for  instance,  is  an  auto-intoxication  by  grape 
sugar,  which  is  in  this  case  a  product  of  disturbed  metabolism,  and 
does  not  originate  from  the  digestive  canal. 

The  dangers  which  threaten  the  general  organism  from  the  intes- 
tinal bacteria  have  given  rise  to  many  efforts  to  sterilize  the  digestive 
tract  by  means  of  so-called  antiseptics.  Most  of  the  agents  used 
for  this  purpose — calomel,  salol,  naphthalin,  beta-naphthol,  bis- 
muth, creosote,  bismuth  salicylate — are  themselves  toxic,  and,  in 
doses  sufficiently  large  to  reduce  the  number  of  bacteria  to  any 
considerable  extent,  they  are  harmful  to  the  body.  The  putrefac- 
tion of  proteids,  as  measured  by  combined  and  ethereal  sulphates 
in  the  urine,  can  only  be  temporarily  diminished  by  this  method. 

Intestinal  disinfection  is  therefore  an  unsolved  problem.  Efforts 
in  this  direction  should  still  be  encouraged,  because  we  may  be 
able  thereby  to  attenuate  the  pathogenic  inhabitants  of  our  intes- 
tines and  render  them  less  virulent.  The  best  disinfectant  of  the 
human  intestine  is  its  normal  action,  and  the  best  way  to  control 
putrefaction  is  by  selection  of  adapted,  appropriate  diet,  fresh  air, 
moderate  exercise,  good  sleep,  pure  water,  avoidance  of  overeating, 
overdrinking,  and  of  chemicals.  (Hemmeter  "  On  Intestinal  Putre- 
fation  and  Albuminuria" — Maryland  Medical  Journal,  July  24  and 
31,  and  August  7,  1897.) 


CHAPTER  VIT. 

EFFECTS  OF  CONTEMPORANEOUS  ACTION  OF  SEVERAL 

DIGESTIVE     SECRETIONS— METHODS     FOR 

TESTING  THE  MOTOR  FUNCTIONS 

OF  THE  STOMACH. 

When  the  gastric  chyme  enters  the  duodenum  the  albuminoid 
and  proteid  foods  appear  partly  as  syntonin,  albumoses,  and  pep- 
tones, and  partly  unchanged.  The  carbohydrates  appear  either  as 
erythrodextrin,  achroodextrin,  or  maltoses,  and  partly  unchanged. 
The  fats  are  unchanged  ;  rarely  are  they  found  split  up,  so  that 
one  can  detect  traces  of  fatty  acids. 

Water,  according  to  the  interesting  investigations  of  von  Mehr- 
ing,  is  absorbed  only  in  very  small  quantities  from  the  stomach.  It 
appears  that  fully  90  per  cent,  of  all  water  taken  into  the  stomach 
is  passed  into  the  duodenum  ;  alcohol,  and  whatever  is  in  solution 
in  it,  is  absorbed  readily.  Grape-,  milk-,  and  cane-sugar,  also  mal- 
tose, are  absorbed  in  moderate  amounts  when  they  are  in  aqueous 
solution  ;  when  they  are  in  alcoholic  solution,  larger  amounts  are 
absorbed.  Dextrin  and  peptone  are  also  taken  up  from  the 
stomach,  but  in  smaller  quantities  than  sugar.  The  amount  of  the 
substances  resorbed  increases  with  the  concentration  of  the  solu- 
tion. Simultaneously  with  this  resorption,  a  more  or  less  active 
secretion  of  water  occurs  into  the  stomach.  This  secretion  of 
water  into  the  stomach  increases  or  diminishes  as  the  quantity  ot 
substances  resorbed  or  taken  up  increases  or  diminishes. 

Secretion  of  water  occurs  even  when  no  HCl  is  demonstrable  in 
the  normal  stomach.  The  chyme,  then,  as  it  enters  the  duodenum, 
still  contains  all  of  its  water,  but  is  minus  some  of  the  peptones, 
dextrins,  sugars,  and  alcohols.  It  is  more  or  less  acid  from  free  HCl. 
When  the  bile  acts  on  this  acid  chyme,  a  resinous,  flocculent  pre- 
cipitate is  deposited  from  it  on  the  walls  of  the  duodenum;  at  the 
same  time  a  finely  granular  cloudiness  occurs.  The  resinous  deposit 
consists  of  bile-acids  and  syntonin  (Hammarsten),  and  the  granu- 
lar opacity  is  due  also  to  bile-acids  and  small  amounts  of  peptone. 

66 


INTERACTION    OF    DUODENAL    SECRETIONS.  6/ 

Excess  of  bile  may  redissolve  these  precipitates  so  that  they  can 
not  at  times  be  found  in  animals  killed  at  the  height  of  digestion. 
The  digestion  by  pepsin  is  checked  by  the  complete  neutralization 
of  HCl  by  pancreatic  juice,  bile,  and  succus  entericus.  If  any  pre- 
cipitation occurs  as  stated,  pepsin  is  also  thrown  down  and  resorbed 
again  or  digested  by  trypsin.  The  bile  does  not  disturb  the  pro- 
teolytic power  of  pancreatic  juice  (Claude  Bernard).  Boas  and  the 
author  hav-e  shown  that  the  clear  duodenal  chyme  will  digest  8i 
per  cent,  of  serum-albumin  in  three  hours  ;  at  40°  C.  its  alkalinity 
was  0.8  per  cent.,  Na^Cog.  It  was  also  shown  that  this  duodenal 
chyme  converted  25  per  cent,  of  starch  into  maltose,  and  that  it 
produced  12.1  per  cent,  fatty  acids  from  neutral  olive  oil  in  three 
hours.  Boas  obtained  his  mixture  of  bile,  pancreatic  juice,  and 
succus  entericus  from  a  patient  who  had  most  probably  a  duodenal 
stenosis  and  who  vomited  this  chyme  frequently.  In  the  author's 
experiments  the  duodenal  secretions  were  obtained  by  his  method 
of  intubation  of  the  duodenum. 

It  was  found  in  these  experiments  that  the  duodenal  juices,  when 
filtered,  digested  85  per  cent,  to  95  percent,  of  Merck's  dried  serum- 
albumin  in  three  hours  at  40°  C.  The  author's  results  with  starch 
conversion  show  that  the  filtered  duodenal  juices  will  digest  42  per 
cent,  of  starches,  or  rather  convert  them  into  maltose,  which  is  con- 
siderably in  excess  of  the  figures  obtained  by  Boas.  The  fat- 
splitting  effect  observed  by  us  in  this  juice  was  again  more  near  the 
result  of  Boas,  for  we  found  that  15.3  per  cent,  of  fatty  acids  were 
obtained  from  neutral  olive  oil.  In  a  case  of  biliary  calculi,  we  have 
been  able  to  obtain  the  pancreatic  juice  free  from  bile,  as  the  bile- 
ducts  must  have  been  stenosed  either  by  a  small  calculus  or  a  bit 
of  thickened  bile  and  mucus  mixed. 

The  fat-splitting  effect  of  pancreatic  juice  is  improved  by  the 
presence  of  bile,  as  is  also  the  amylolytic  action  of  amylopsin. 

Deinonstratio)i. — The  action  of  pancreatic  juice  obtained  from  a 
dog  on  neutral  olive  oil  and  on  a  solution  of  starch  should  be 
studied  both  with  and  without  bile.  Pancreatic  juice  plus  bile  will 
split  up  more  fat  and  convert  more  starch  into  maltose  than 
without  bile  (^lartin  and  Williams). 

The  effect  of  trypsin  on  pepsin  is  not  definitely  known,  but  it  is 
probable  that  pepsin,  being  closely  allied  to  proteids,  is  disintegrated 
by  trypsin,  but,  in  an  acid  solution,  pepsin  checks  the  action  of  trypsin 
(Kiihne,  Langley,  Ewald,  and  Baginsky).     According  to  Baginsky, 


68  NATURE    OF    CONTENTS    OF    ILEUM    AND    COLON. 

rennin  is  destroyed  by  a  neutral  solution  at  room  temperature. 
The  ferment  action  of  bacteria  in  the  small  intestine  is  limited 
to  the  carbohydrates.  Discharges  of  food  from  fistulae  of  the  small 
intestine  show  no  fetid  decomposition  of  albuminoids  (Ewald  and 
Nencki).  The  absence  of  proteid  putrefaction  in  the  small  intestine 
is  probably  due  to  the  rapid  downward  movement  of  the  food  mass 
in  this  portion  of  the  bowel  and  to  its  acid  condition. 

Carbohydrate  fermentation  yields  mainly  lactic  acid,  ethyl 
alcohol,  carbon  dioxid,  and  hydrogen.  Macfadyen,  Nencki,  and 
Sieber  found  the  chyme  that  passed  over  into  the  large  intestine 
(the  cecum)  from  the  ileum  to  be  550  gm.,  with  4.9  per  cent,  solid 
residue  in  case  the  chyme  was  of  a  very  thin  consistence  ;  and  232 
gm.,  with  TI.23  per  cent,  solid  residue,  if  the  chyme  was  very  con- 
densed. Both  of  these  figures  are  the  amounts  passing  in  twenty- 
four  hours.  The  shortest  time  in  which  food  passed  into  the  cecum 
after  it  was  swallowed  was  two  hours;  the  longest  period,  five  and 
and  a  quarter  hours. 

The  reaction  expressed  in  acetic  acid  was  equal  to  one  per 
thousand ;  the  acidity  is  considered  to  be  due  to  newly  formed 
acetic  acid,  as  the  lactic  acid  and  the  HCl  are  neutralized  by  the 
succus  entericus.  This  chyme  contained  i  per  cent,  albumin  ;  also 
peptone,  mucin,  dextrin,  sugar,  lactic  acid,  sarcolactic  acid,  and 
traces  of  fatty  acids  ;  it  contained  no  leucin,  tyrosin,  urobilin,  or 
ammonia.  The  characteristic  products  of  albuminoid  decomposi- 
tion were  absent. 

Jaworski's  investigations  on  the  contents  of  the  large  intestine, 
which  were  discharged  from  a  fistula  in  the  ascending  colon,  showed 
that  the  daily  fecal  discharge  of  150  to  200  gi'^s,  was  decidedly 
alkaline,  and  contained  the  products  of  proteid  and  albuminoid 
decomposition,  viz.:  urobilin,  skatol,  phenol,  oxyacids,  ammonia, 
leucin,  cadaverin,  ethyl  and  butyl  alcohol,  sulphuretted  hydrogen, 
and  methyl  mercaptan. 

In  view  of  the  fact  that  the  putrefaction  of  albuminoids  and  pro- 
teids  occurs  mainly  in  the  colon,  it  is  of  interest  to  know  how  much 
of  this  class  of  food  substances  is  left  for  the  colon,  and  how  much 
is  digested  in  the  small  intestine.  Nencki  found  that  when  the  food 
contained  70.74  gm.  albumin,  which  represent  10.602  gm.  nitrogen, 
the  amount  of  solid  material  discharged  from  a  colon  fistula  in 
twenty-four  hours  was  26.5  gm.,  with  1.61  gm.  nitrogen,  which 
represented   10.06  gm.  albumin.     From  this  it  is  evident  that  14.25 


ULTIMATE    FATE    OF    DIGESTIVE    FERMENTS.  69 

per  cent.,  or,  in  other  terms,  only  one-seventh  of  the  total  albumin, 
is  left  for  digestion  in  the  colon,  and  that  85.75  P^^  cent,  is  re- 
sorbed  from  the  stomach  and  small  intestine. 

The  intensity  of  putrefaction  in  the  colon  depends  upon  four 
factors:  (i)  The  amount  of  decomposable  albuminoid  materials  in- 
gested ;  (2)  the  duration  of  their  retention  in  the  colon ;  (3)  the 
vigor  and  tonicity  of  the  intestinal  peristalsis ;  and  lastly  (4)  the 
chemical  reaction,  for  a  very  strong  acid  reaction,  due  to  free 
acids,  inhibits  putrefaction. 

Bile  assists  in  this  inhibition.  Hirschler  has  demonstrated  that 
carbohydrates  suppress  putrefaction  considerably ;  this  is  due  to 
the  lactic,  butyric,  acetic,  and  carbonic  acids  caused  by  their  fer- 
mentation. Albumin  and  peptone  are  absent  from  the  contents  of 
the  rectum  (feces),  but  are  present  in  typhoid  fever  (von  Jaksch). 
Peptone  is  found  in  all  diseases  that  may  produce  pus  in  the  evacua- 
tions,— for  instance,  dysentery,  tuberculous  intestinal  ulcers,  perfora- 
tion, peritonitis,  hepatic  cirrhosis,  and  carcinoma. 

A  very  important  inquiry  is  that  into  the  ultimate  fate  of  the 
digestive  ferments :  Do  they  pass  through  the  entire  intestinal 
tract  ?  Are  they  absorbed  or  are  they  decomposed  ?  Or  do  they 
appear  in  their  active  form  in  the  feces  ?  This  question  is  a  very 
difficult  one  to  solve,  as  our  only  method  of  detecting  pepsin,  rennin, 
trypsin,  and  ptyalin  is  by  their  digestive  activity.  In  all  experi- 
ments of  this  kind  the  feces  must  be  first  sterilized  by  saturated 
solutions  of  thymol ;  before  using  this  it  is  well  to  exclude  the 
action  of  peptonizing  bacteria  by  filtering  through  a  Pasteur  filter. 

If  we  found  in  the  glycerin  extract  of  the  sterilized  feces  a  sub- 
stance which  would  dissolve  boiled  egg-albumen  in  a  solution  of 
0.2  per  cent.  HCl,  we  should  be  justified  in  concluding  that  it  was 
pepsin.  If  it  did  not  digest  in  HCl,  but  in  a  one  per  cent,  solution 
of  sodium  carbonate,  it  would  probably  be  trypsin. 

For  the  demonstration  of  a  diastatic  ferment  a  dilute  solution  of 
starch  is  brought  into  the  incubator  with  about  five  c.c.  of  filtered, 
sterilized  feces.  After  a  few  hours  the  HCl  and  soda  solutions  of 
the  boiled  albumin  are  tested  for  peptone  by  the  biuret  reaction, 
and  the  diastatic  test-tube  is  tested  with  a  dilute  solution  of  iodin 
in  iodid  of  potassium.  If  the  starch  is  unchanged  the  solution 
will  be  changed  to  blue;  if  not,  the  color  will  be  brown  or  yellow. 

In  this  way  we  have  confirmed  the  fact  that  pepsin  is  absent 
from  the  colon  contents,  but  trypsin  is  at  times  present,  since  the 


/O  FATE    OF    DIGESTIVE    FERMENTS. 

perfectly  sterile  extract  of  feces  will  digest  fibrin  and  albumin  in 
alkaline  solution. 

The  digestive  action  of  the  succus  entericus,  which,  according  to 
Griitzner,  has  a  weak  fibrin-dissolving  property,  does  not  extend  to 
the  albumins,  and  therefore  it  will  not  confuse  the  result  stated 
above  as  pertaining  to  pepsin  and  trypsin. 

The  chief  digestive  action  of  succus  entericus  is  on  the  carbohy- 
drates. If  peptone  occurs  in  the  stools,  it  is,  in  the  author's 
opinion,  a  product  either  of  pepsin  or  trypsin  digestion,  not  of 
bacterial  origin.  Undoubtedly,  there  are  proteolytic  bacteria, — for 
instance,  the  bacillus  subtilis  of  Ehrenberg,  the  proteus  vulgaris  of 
Hauser,  the  bacillus  putrificus  coli  of  Bienstock,  and  the  bacillus 
liquefaciens  ilei  of  Macfadyen,  Nencki,  and  Sieber,  all  of  which 
exist  ordinarily  in  the  human  intestine;  and  their  first  products  of 
action  on  albumins  are  the  same  as  occur  in  normal  pancreatic 
digestion,  viz.:  albumoses,  peptones,  amido-acids,  and  ammonia; 
but  then  the  action  continues  uninterruptedly,  ending  in  the  forma- 
tion of  decomposition  products  stated  in  a  previous  paragraph. 
The  bacterial  product  of  peptone  is  probably  of  no  use  to  the 
organism  in  which  it  occurs, — it  is  a  first  stage  to  proteid  putrefac- 
tion, and  these  proteolytic  parasites  need  peptone  for  their  own 
existence. 

The  remote  possibility  that  bacteria  could  produce  peptone  in 
the  colon  (feces)  might  be  excluded  by  the  fact  that  after  steriliza- 
tion of  the  feces  by  a  saturated  solution  of  thymol,  peptone  will,  in 
some  cases,  still  be  produced  when  the  above  tests  are  made.  It  is 
due  most  probably  to  trypsin,  which  is  present  in  the  stools  when 
they  have  traversed  the  intestines  rapidly. 

Starch-inverting  ferments  are  present  in  the  saliva,  pancreatic 
juice,  and  succus  entericus;  hence,  if  such  a  ferment  appears  in  the 
feces,  it  is  impossible  to  decide  upon  its  source. 

Amylopsin  and  steapsin  have  not  been  demonstrated  as  such  in 
normal  feces.  It  is  not  known  whether  pepsin  and  rennin  occur 
in  normal  feces.  We  have  found  a  proteid-dissolving  ferment 
in  the  stool,  which  acted  in  a  one  per  cent,  solution  of  carbonate 
of  sodium  only,  and  was  studied,  in  a  case  of  complete  atrophy  of 
the  gastric  mucosa,  with  total  absence  of  HCl,  pepsin,  and  ren- 
net, and  also  of  the  pro-enzymes  of  these  ferments.  In  the  wash 
water,  bits  of  mucosa  were  found  that  proved  the  absolute  destruc- 
tion of  the  glandular  apparatus  of  the  stomach. 


MOTOR    FUNCTIONS    OF    THE    STOMACH.  J I 

It  is  probable  that  this  ferment  was  trypsin.  There  was  a  mod- 
erate g-astrectasia  but  otherwise  no  anatomical  defect  observable. 

The  stools  were  not  diarrheic.  Escherich's  assertion  that  the 
colon  bacteria  do  not  live  upon  the  food  introduced, — as,  according 
to  his  opinion,  there  is  no  digestible  food  left  there  under  normal 
conditions, — but  that  they  live  upon  the  secretions  of  the  walls  of 
the  colon  is  certainly  erroneous — if  this  statement  of  his  view  is 
correct — (Mannaberg,  in  Nothnagel's  "  Erkrankungen  des  Darms," 
p.  38). 

The  conception  of  some  writers  on  this  subject,  that  food  mate- 
rials are  completely  used  up  in  the  digestive  tube,  is  not  proven  by 
actual  fact.  Even  meat,  when  eaten  in  a  most  digestible  form,  is 
found  undigested  to  a  small  extent  in  the  evacuations.  It  is  there- 
fore more  than  probable  that  the  colon  bacteria  live  at  the  expense 
of  the  ingested  proteid  food. 

Having  thus  far  reviewed  the  physiology,  anatomy,  and,  in  part, 
the  pathology  of  food  digestion  in  general,  let  us  now  return  to  the 
special  pathology  of  the  functions  of  the  stomach,  as  a  preparation 
for  a  better  comprehension  of  its  diseased  states. 

Qualitative  and  Quantitative  Methods  for  Testing  the  Motor 
Functions  of  the  Stomach. — The  motor  or  peristaltic  function 
is  the  most  important  one,  because  a  man  may  be  able  to  live 
without  the  secretory  and  resorptive  functions  of  his  stomach, 
as  the  intestinal  digestion  and  secretion  would  suffice  for  the  con- 
version of  carbohydrates  and  proteolysis,  and  he  depends  upon 
the  small  intestine  altogether  for  the  digestion  and  absorption 
of  fats  ;  so  that  even  in  the  total  absence  of  gastric  resorption  and 
the  falling  away  of  secretions  of  HCl,  pepsin,  and  rennin  ferments, 
life  could  be  maintained. 

But  if  the  motor  function  is  interfered  with,  the  food  would  1 
remain  in  the  stomach  and  accumulate.  If  a  normal  gastric  juice 
were  even  possible  when  the  peristalsis  is  paralyzed,  the  food  could 
be  only  partly  digested.  Carbohydrates  and  fats  would  not  be 
digested.  When  the  limit  of  distention  was  reached  the  food 
would  be  ejected  (pyloric  stenosis;  gastrectasia). 

In  all  cases  of  inhibition  or  loss  of  motor  power,  the  secretory 
power  is  seriously  disturbed  or  may  cease  absolutely;  so  also  the 
resorptive  power.  Many  cases  of  total  absence  of  gastric  secretions 
have  been  reported  in  patients  whose  body  weight  continued 
normal    and  their   general  health  unimpaired.     The  stomach  has 


72  TESTING    THE    GASTRIC    MOTOR    FUNCTIONS. 

been  removed  experimentally  in  dogs,  and  the  animals  continued 
to  thrive  without  it  if  precautions  were  taken  in  providing  finely- 
divided  food. 

There  have  been,  up  to  very  recently,  six  different  methods  pro- 
posed for  determining  the  motor  functions  of  the  human  stomach  : 
the  methods  of  Leube,  Ewald  and  Sievers,  Klemperer,  Fleischer, 
Einhorn,  and  Hemmeter. 

Leube's  method  of  estimating  the  duration  of  gastric  digestion — 
i.  e.,  to  determine  after  a  definite  average  time  of  six  to  seven  hours 
after  a  meal  of  50  gm.  bread,  200  gm.  beefsteak,  and  a  glass  of  water, 
or  two  hours  after  an  Ewald  test-breakfast,  whether  solid  contents 
were  still  to  be  found  in  the  stomach — will  serve  the  practitioner 
with  a  simple  and  ready  method,  which  follows  naturally  in  the 
line  of  drawing  test-meals  from  the  stomach  ;  it  is,  however,  sub- 
ject to  too  many  physiological  variations  to  permit  of  accurate 
deductions. 

Ewald  has  proposed  the  use  of  salol,  which,  according  to  Nencki, 
is  not  decomposed  by  acids  in  the  stomach,  but  is  converted,  by 
the  alkaline  juices  of  the  duodenum,  into  salicylic  acid  and  phenol. 
He  found,  in  connection  with  Sievers,  that  the  appearance  of 
salicyluric  acid — the  product  of  the  decomposition  of  the  salol 
in  the  urine — would  indicate  that  the  salol  had  actually  passed  out 
of  the  stomach. 

Normally,  salicyluric  acid  will  appear  in  the  urine  from  forty  to 
seventy-five  minutes  after  taking  one  gm.  of  salol.  Delay  in  its 
appearance  will  indicate  a  retardation  in  the  passage  of  food  into 
the  intestines. 

Salicyluric  acid  is  recognized  in  the  urine  by  the  violet  color 
produced  on  the  addition  of  neutral  ferric  chlorid  solution.  This 
method  necessitates  frequent  urination  of  the  patient — every  five 
minutes,  at  least ;  otherwise  the  result  will  not  be  accurate. 

Brunner,  Riegel,  and  Eichhorst  found  that  the  time  in  which  the 
reaction  occurred  in  the  healthy  individual  varied  from  forty 
minutes  to  two  hours.  This  was  to  be  anticipated,  as  the  period 
during  which  a  test-meal  may  remain  in  the  stomach  may  vary 
normally  between  two  and  three  hours. 


CHAPTER   VIII. 

METHODS  FOR  TESTING  THE  GASTRIC  PERISTALSIS 

(Continued). 

As  Evvald's  salol  test  is  not  applicable  in  private  practice,  because 
of  the  frequent  micturition  that  is  necessary,  it  is  impossible  to 
examine  females  by  this  method  ;  and,  also,  because  the  excretion 
of  salicyluric  acid  depends  upon  the  changing  energy  of  the  heart's 
action,  intra-arterial  pressure,  the  amount  of  water  in  the  blood, 
and  the  changeable  function  of  the  kidneys  themselves. 

Huber  improved  this  method  somewhat  by  ascertaining  that 
salicyluric  acid  disappears  from  the  urine,  after  the  administration  of 
salol  to  healthy  persons,  in  twenty-four  hours  ;  but  in  patients  with 
impaired  gastric  peristalsis,  the  reaction  continues  to  be  distinct 
much  longer, — sometimes  for  forty-eight  hours.  According  to 
Fleischer  and  Hecker,  the  duration  of  excretion  of  potassium  iodid 
in  the  urine  of  healthy  individuals  varies  from  twenty-nine  to  fifty- 
five  hours ;  of  sodium  salicylate,  from  twenty-one  to  twenty-nine 
hours;  and  in  cardiac  and  nephritic  patients  this  may  vary  from 
eighty  to  ninety-six  hours.  It  is  evident  that  methods  of  such  a 
variable  character  are  not  satisfactory  for  exact  research  ;  nor  even, 
on  account  of  the  great  loss  of  time,  of  much  value  for  compara- 
tive tests. 

Klemperer's  method  consists  in  the  introduction  of  lOO  gm.  of 
neutral  olive  oil  into  the  perfectly  clean  stomach,  after  lavage, 
through  a  stomach-tube.  Oil  or  fatty  acids,  which  are  formed  in 
traces,  are  not  absorbed  from  the  stomach.  After  two  hours,  all 
oil  yet  remaining  is  washed  out  by  repeated  lavage,  dissolved  in 
ether,  and  weighed  after  removal  of  the  ether  by  distillation.  In 
the  normal  subject  Klemperer  could  find  but  20  to  30  gm.  of  oil; 
the  remaining  70  to  80  gm.  had  passed  into  the  intestine.  If  larger 
amounts  are  found — for  instance,  50  to  60  gm.,  or  more — they  are, 
according  to  Klemperer,  an  evidence  of  motor  insufficiency.  This 
method  requires  much  time  and  skilled  chemical  analysis,  and  is 
also  open  to  the  same  objection  as  that  of  Leube. 

72> 


74  METHOD    FOR    TESTING    THE    GASTRIC    PERISTALSIS. 

Fleischer  ("  Spez.  Path.  u.  Therap.  d.  Magen-  u.  Darmkiankh.," 
p.  791)  has  proposed  a  method  to  determine  the  gastric  peristalsis 
by  giving  0.1  gr.  iodoform  in  a  gelatine  capsule  during  meals; 
this  compound  does  not  decompose  in  acid  media,  but  does  break 
down  in  the  alkaline  juices  of  the  duodenum,  and  one  of  its  result- 
ants is  potassium  iodid,  which  can  be  tested  in  saliva  by  starch 
paper,  which,  when  dipped  into  the  saliva,  colors  blue  on  being 
touched  with  a  drop  of  fuming  nitric  acid.  Naturally  the  potassium 
iodid  can  also  be  detected  in  the  urine  ;  but  the  fact  which  gives 
this  method  the  preference  over  Ewald's  salol  test  is  that  the  KI 
can  be  detected  in  the  saliva. 

It  is  quite  a  xariable  experiment,  as  we  have  discovered.  In 
twenty-three  cases  in  which  we  have  tried  it,  the  reaction  coloring 
the  starch  paper  first  occurred  just  one  hour  after  the  meal,  in  tweh-e 
cases;  in  si.v  cases  it  occurred  first  in  one  hour  and  twenty  to 
twenty-two  minutes;  in  two  cases,  in  one  hour  and  forty-one  min- 
utes ;  and  in  one  case  in  two  hours.  In  two  cases  it  took  two 
hours  and  a  half  to  demonstrate  KI  in  the  mouth,  after  giving  o.i 
iodoform. 

These  were  cases  in  which  the  gastric  secretions  were  known  to 
be  normal.  The  time  of  the  appearance  of  the  first  red  and  the 
subsequent  blue  coloring  of  the  starch  paper  was  carefully  noted. 
Fleischer  states  that  after  a  test-breakfast  the  reaction  in  the  saliva 
should  occur  in  from  fifty-five  to  one  hundred  and  five  minutes, 
which  is  still  a  considerable  margin  for  variations — too  great  fur 
practical  purposes. 

Nevertheless,  the  method  is  interesting,  and,  with  exactly  known 
meals,  might  be  available  for  hospital  work. 

In  Leube's,  Ewald's  and  Sievers',  Klemperer's,  and  Fleischer's 
methods,  it  will  be  observed  that  the  gastric  motility  was  deter- 
mined by  something  that  was  administered  (salol,  iodoform,  and 
food)  or  poured  into  the  stomach  foil),  and  by  the  absorption  of 
the  product  of  breaking  down  in  the  alkaline  duodenum,  and  its 
subsequent  appearance  in  the  secretions  and  excretions  (potassium 
iodid  in  the  saliva  and  salicyluric  acid  in  the  urinej — an  expression 
in  terms  of  time  was  arrived  at,  to  denote  the  intensity  of  the  gas- 
tric peristalsis. 

In  two  methods  the  expression  is  derived  from  the  quantity  of 
oil  or  food  retained  in  the  stomach  after  two  hours,  but  here  also 
the  result  depended  upon  the  passage  of  something  into  the  duo- 


PLATE  111. 


Patient  with  Intragastric  Bag  within  Stomach  and  Pneumograph  in  Place, 
Both  Connected  with  the  Kymograph. 


PLATE  IV. 


The  apparatus,  not  including  kymograph.  G.  Intragastric  bag  distended.  F.  The 
esophageal  tube  attached  to  it.  H.  Intragastric  bag  collapsed  in  the  shape  it  is 
introduced.  A.  Pressure  bottle  elevated  and  filled  with  water  and  graduated. 
B.  Stop-cock.  D.  Lower  graduated  bottle,  empty  at  first.  The  bag  is  distended 
after  it  is  swallowed  by  connecting  it  at  E  with  D  ;  the  stop-cock,  B,  is  turned  on, 
and  the  water  then  runs  from  A  to  D,  displacing  the  air  in  D  and  forcing  it  into 
the  bag.  Both  bottles  being  graduated,  the  amount  of  air  in  G  is  always  known 
and  can  be  utilized  as  an  indication  of  the  gastric  capacity. 


THE    GASTROGRAPH.  75 

denum.  In  all  of  these  methods,  therefore,  the  fundamental  idea  is 
the  rate  of  expulsion  of  gastric  contents  into  the  duodenum,  as  if 
that  were  the  only  object  of  the  motor  functions  of  the  stomach. 

It  is  probable  that  this,  which  is  only  a  part  of  the  purpose  of 
the  gastric  peristalsis,  was  so  much  dwelt  upon  because  it  offered 
the  most  expedient  means  for  experimenting,  and  a  greater  possi- 
bility of  solution  of  the  problem.  However,  a  second  and  most 
important  purpose  of  the  gastric  peristalsis,  and  one  concerning 
which  none  of  the  methods  referred  to  thus  far  can  instruct  us,  is 
the  moving  about  of  the  ingesta  within  the  stomach,  (i)  so  that  they 
may  be  made  into  a  more  homogeneous  mass,  (2)  so  that  they  may 
be  brought  into  thorough  contact  with  the  gastric  juice,  and  (3)  to 
stimulate  the  secretion  of  this  juice  by  the  mechanical  irritation  of 
the  walls  of  the  organ. 

These,  in  addition  to  expelling  the  chyme,  are  the  purposes  of 
the  motor  function.  The  secretion  of  the  gastric  glands  is  not  only 
stimulated  by  the  mechanical  irritation  of  the  stomach-walls  during 
peristalsis,  but  by  the  contraction  of  a  liberal  supply  of  muscular 
fibers,  which  arise  from  the  muscularis  mucosa,  and  are  spun 
around  the  fundus  or  bases  of  the  gland  tubules  (see  frontispiece 
lithograph  of  normal  gastric  mucosa) ;  the  glands  are  no  doubt 
themselves  contracted  and  their  contents  expelled. 

In  some  of  the  batrachians  this  contraction  of  the  gastric  gland 
tubules  by  electric  stimulation  is  visible  under  the  microscope. 

Dr.  Max  Einhorn  has  described,  in  the  Nezv  York  Medical  J ozir- 
««/,  September  15,  1894,  an  instrument  which  records  the  gastric 
movements  by  dots  on  a  narrow  piece  of  paper. 

This  apparatus  consists  of  a  ball  about  ^^  of  an  inch  (14  mm.) 
in  diameter,  which  is  made  up  of  two  hollow  metallic  hemispheres 
screwed  together.  Within  this  is  contained  a  second  smaller  ball, 
which  is  attached  to  the  upper  hemisphere  by  a  non-conductor  so 
that  it  is  insulated  from  it. 

The  central  smaller  ball  bristles  with  small  metallic  spikes  which 
radiate  in  all  directions  from  the  center  to  the  inside  of  the  two 
hemispheres,  but  not  touching  them. 

A  tiny  platinum  sphere  completes  the  interior  of  this  apparatus  ; 
it  lies  within  the  larger  round  capsule  and  moves  about,  knocking 
at  the  spikes.  When  it  does  so,  it  completes  an  electric  circuit 
between  the  outer  hemispheres  and  the  spikes  of  the  central  ball, — 


76  METHODS    FOR    TESTING    THE    GASTRIC    PERISTALSIS. 

for  two  insulated  wires,  one  connected  with  the  hollow  ball,  the 
other  with  the  spiked  ball,  run  up  in  a  very  fine,  thin,  rubber  tube 
and  are  connected  with  the  two  poles  of  an  electric  battery.  On 
connecting  the  ball  with  another  part  of  the  apparatus,  the  "ticker" 
(very  much  like  the  instrument  used  at  the  stock  exchanges  for 
reporting  the  variations  in  stock  by  telegraph)  each  motion  of  it 
will  be  recorded  by  lines  or  dots  on  the  paper.  The  ball  is 
swallowed  and  brought  into  the  stomach  by  the  aid  of  a  draught 
of  water.  It  must  be  borne  in  mind  that  the  paper  records  the 
motions  of  the  ball  only;  this  does  not  mean  that  it  records  every 
motion  of  the  gastric  peristalsis. 

In  animals  upon  which  we  experimented  at  the  biological  labo- 
ratory of  the  Johns  Hopkins  University,  a  rubber  stomach-shaped 
bag  was  fitted  exactly  to  the  interior  of  the  animal's  stomach  and 
connected  with  a  manometer  on  the  Ludwig  kymographion. 
Records  were  taken  with  the  animal's  abdomen  intact  and  com- 
pared with  those  with  the  abdomen  opened,  so  that  the  gastric 
peristalsis  could  be  viewed  by  the  experimenter. 

The  physiological  peristalsis  is  essentially  the  same  whether  the 
animal's  stomach  is  normally  contained  within  the  abdomen  or 
exposed  to  view. 

In  our  experiments  the  animals  were  placed  in  a  large  metal 
case  with  a  glass  top;  underneath  the  animal  holder  about  two 
inches  of  water  was  contained  in  the  bottom  of  the  case,  which  was 
kept  at  any  desired  temperature  by  a  number  of  Bunsen  burners 
beneath  the  case.  Thermometers  were  suspended  from  different 
parts  of  the  case  to  keep  watch  on  the  temperature,  for  it  is  most 
essential  that  after  an  animal's  abdomen  has  been  opened  it  should 
be  kept  at  a  constant  temperature  by  moist  steam  ;  this  also  insures 
the  viscera  against  becoming  dry. 

In  a  similar  manner  Ludwig  and  H.  Newell  Martin  studied  the 
physiology  of  the  mammalian  heart ;  Schatz  conducted  his  funda- 
mental investigations  on  the  contractions  of  the  uterus  ;  Engelmann 
carried  on  his  pioneer  work  on  the  contraction  of  the  involuntary 
muscle-fibers  of  the  ureter.  Phliiger  and  Heidenhain  have  done 
similar  accurate  work  on  excised  organs,  and  the  results  have 
been  repeatedly  confirmed  by  other  competent  investigators. 

These  epoch-making  experimentations  are  mentioned  to  empha- 
size the  fact  that  experiments  conducted  on  organs  isolated  either 


INTROGASTRIC  APPARATUS.  77 

entirely  (Martin,  Ludwig,  Engelmann)  or  partially  (Schatz,  Phliiger) 
are  capable  of  giving  perfectly  physiological  contractions  or  peris- 
talsis which  differ  nowise  from  the  perfectly  normal  ones. 

It  is  frequently  urged  that  these  experiments,  on  account  of  the 
operations  and  the  anesthesia  necessary,  do  not  present  perfectly 
physiological  conditions,  and  that  therefore  the  deductions  made 
therefrom  are  not  logical,  nor  represent  the  true  state  of  normal 
functioning. 

It  is  undeniable  that  we  never  get  at  the  absolutely  exact  normal 
functioning  of  an  organ — the  stomach,  for  instance — during  an 
experiment,  as  ether  and  chloroform  have  an  inhibiting  effect  on 
gastric  peristalsis.  But  we  are  enabled  to  produce  unconscious- 
ness of  the  animal  after  a  brief  ether  narcosis  by  brain  com- 
pression, after  which  the  ether  is  no  longer  necessary,  and  then 
the  gastric  peristalsis  continues  perfectly  normal.  The  stomach  of 
the  rabbit  will  show  normal  peristalsis  after  complete  excision  and 
suspension  on  a  hook  or  clamp  in  a  warm,  moist  chamber. 

What  brought  us  to  the  idea  of  using  an  intragastric  thin 
rubber  bag  to  record  the  peristalsis,  after  many  attempts  with  a 
small  spherical  bag  that  did  not  exactly  fill  out  the  entire  lumen 
of  the  stomach,  was  the  repeated  observation  that  the  small, 
round  bag,  such  as  Professor  Moritz,  of  Munich,  used,  did  not 
record  every  peristaltic  movement  that  was  visible  to  the  eye 
when  the  abdomen  was  opened. 

We  frequently  noticed  peristaltic  constrictions  of  the  antrum 
pyloricum  when  the  rubber  bag,  of  about  12  cm.  in  diameter,  was 
at  the  cardia  or  fundus,  and  recorded  no  movement  but  that  due  to 
the  pressure  caused  by  the  descent  of  the  diaphragm.  We  con- 
cluded, after  three  months'  experimentation,  that  a  small  intra- 
gastric apparatus  could  not  possibly  record  every  peristaltic 
movement. 

Sometimes  one  could  witness  very  strong  tonic  contractions  of 
seemingly  every  muscle-fiber  of  the  stomach, — it  gave  that  impres- 
sion,— by  which  the  whole  organ  contracted  from  all  sides  by 
shortening  of  every  circular,  oblique,  and  longitudinal  fiber,  and  at 
the  same  time  the  bag  gave  no  record  of  movement,  although 
when  it  was  lying  in  the  fundus  it  was  clearly  being  lifted  up, — it 
would  not  record  until  it  was  compressed  by  food  or  the  opposite 
gastric  wall. 

For  these  reasons  a  bag  was  devised  which  had  the  exact  shape 


yS  METHODS    FOR    TESTING    THE    GASTRIC    PERISTALSIS. 

of  the  Stomach,  but  could  readily  be  swallowed,  and  when  dis- 
tended within  the  organ,  exactly  adapted  itself  to  its  interior,  filling 
every  nook  and  corner  in  it.  If  a  little  food  was  needed  in  the 
organ,  we  simply  did  not  blow  the  bag  up  so  far  as  to  fill  it  out 
completely. 

Our  apparatus,  as  has  been  demonstrated  many  times  on  a  large 
variety  of  cases  in  the  'clinical  amphitheater  of  our  school,  is 
adjusted  with  great  ease  even  in  patients  who  are  examined  for  the 
first  time.  By  a  pneumograph  the  respiration  is  recorded  sepa- 
rately, and  thus  one  is  enabled  to  differentiate  the  active  from  the 
passive  movements. 

A  separate  seconds-pen  gives  on  the  same  paper  a  record  in  time, 
so  that  the  experimenter  can  tell  at  a  glance  the  duration,  beginning, 
and  end  of  the  peristalsis.  While  it  is  the  most  perfect  apparatus 
yet  devised  for  recording  the  motor  function,  it  offers  a  reliable 
means  of  ascertaining  the  size  and  exact  capacity,  and  finally  the 
intragastric  pressure.  No  apparatus  hitherto  devised  combines 
these  facilities  in  such  a  simple  bit  of  mechanism  ;  for,  taking  away 
the  kymograph,  which  should  be  in  every  medical  school,  its 
important  parts  are  simply  the  intragastric  bag  and  a  manometer. 

In  practice,  a  manometer  connected  with  the  intragastric  bag  will 
answer  ;  with  watch  in  hand  the  experimenter  is  able  to  count  the 
peristaltic  movements  as  they  are  conveyed  to  the  column  of  water, 
Einhorn,  in  his  new  book,  "  Diseases  of  the  Stomach,"  page  96, 
has  gathered  the  impression  that  the  apparatus  is  of  difficult  adjust- 
ment, because  in  our  first  report  {loc.  cit))  we  stated  that  only  such 
patients  are  taken  as  have  become  accustomed  to  the  stomach-tube, 
as  the  nausea  and  vomiting  first  attending  the  initial  introduction 
of  the  tube  make  an  exact  record  impossible  (we  lay  great  stress 
here  on  the  word  exact).  No  intragastric  instrument,  not  even 
Einhorn's  electrode,  can  be  introduced  the  first  time  without  some 
nausea ;  while  this  may  not  lead  to  emesis,  it  nevertheless  has  a 
great  influence  on  the  number  of  gastric  movements,  as  all  cases 
we  have  tried  generally  show  more  contractions  in  the  first  experi- 
ment than  in  any  other.  If  the  record  is  to  be  exact  and  free  from 
objections  that  may  be  urged  on  account  of  the  influence  of  ner- 
vousness, nausea,  suggestion,  etc.,  a  certain  adaptation  and  experi- 
ence of  the  patient  is  indispensable,  no  matter  what  instrument  is 
used.  Probably  none  of  these  apparatuses  will  be  regularly  used  in 
practice;  they  are  implements  for  the  trained  specialists,  who  know 


^rJ  _  ' 

Curve  of  conlraclion  of  slomncli  of  terrapin,  in  which  slow  stimulations—/,  f..  twenty  per  second— are  more  effective  than  rapid  stimulation.     The  number  of  stimu- 
lations can  be  so  increased  per  second  that  the  muscle  will  not  contract  at  all. 


EFFECT  OF  FABAOAIC  STIMUl^TION 


The  slowing  of  the  cardiac  impulse,  as  shown  in  the  gastric  record,  is  not  a  genuine  cardiac  inhibition,  but  only  ■... 
ppnrcnt  one.  due  to  the  fact  that  the  stomach  draws  away  from  the  diaphragm  and  aorta  during  violent  contractions,  and 
ooes  no,  receive  every  impulse  ;  the  radial  pulse  during  this  perio<l  was  undisturbe.l  and  regular.  Distance  of  secondary 
™"  from  primary  coil,  four  cm.  on  the  sliding  apparatus. 


Hemmeter's   triple  intragastric  hag.     Kymographic  record  of  pyloric  (No.  I), 
middle  portion  (No.  2),  and  cardiac  end  of  stomach  (No.  3)  in  successive  peristalsis. 


INTROGASTRIC    APPARATUS.  79 

how  to  apply  them  and  how  to  interpret  their  results.  Neverthe- 
less, our  intragastric  bags  are  used  regularly  at  the  Maryland 
General  Hospital  and  exact  results  obtained  thereby,  even  at  the 
first  experiment. 

Our  objections  to  the  Einhorn  gastrograph  are:  (i)  That  no 
differentiation  between  active  and  passive  movements  is  possible 
thereby;  (2)  that  there  is  no  coincident  record  of  time  in  seconds 
on  the  paper;  (3)  that  the  tonicity  or  intensity  of  a  contraction  can 
not  be  adequately  determined  ;  (4)  that  the  slow  but  very  extensive 
general  tonic  contractions — a  narrowing  down,  as  it  were,  of  the 
entire  stomach  to  one  point  in  the  center — will  probably  be  recorded 
by  a  single  dot,  such  as  would  be  made  by  an  inspiration  also.  At 
the  same  time,  when  we  reflect  that  a  bag  12  cm.  in  diameter  may 
miss  some  of  the  contractions  and  fail  to  record  them,  it  is  difficult 
to  imagine  that  the  gastrograph  should  record  them  all,  being  not 
even  an  inch. in  diameter. 

Nevertheless,  Einhorn's  apparatus  marks  an  epoch  in  the 
history  of  the  study  of  stomach  motions  and  their  physiology.  It  is 
the  first  attempt,  and  largely  a  successful  one,  to  obtain  their  record 
by  mechanical  means. 

Passive  motions  caused  by  the  pulsations  of  the  aorta  and  the 
impulse  of  the  heart  ventricles  against  that  part  of  the  saccus 
coecus  cardiae  which  touches  the  arch  of  the  diaphragm,  and  also 
the  respiratory  passive  motions  due  mostly  to  the  muscles  of  res- 
piration, are,  to  a  small  extent,  participants  in  the  causes  of  gastric 
movements;  but  they  can  not  of  themselves  produce  evacuations  of 
the  contents,  as  we  had  occasion  to  observe  in  the  clinic  on  a  hys- 
terical girl  (R.  H.),  who  had  no  active  stomach  movements,  no 
genuine  peristalsis  at  all,  all  of  her  gastric  movements  being  due  to 
respiration  and  circulation. 

This  girl  showed  a  normal  state  of  the  secretions  after  an  Ewald 
test-meal,  but  at  the  same  time  there  was  stagnation  and  over- 
retention  of  food.  It  is,  therefore,  most  essential  to  be  able  to  dis- 
tinguish between  active  and  passive  movements,  for  a  person  may 
have  a  great  many  movements  of  the  stomach  and  yet  have  no 
genuine  peristalsis  at  all. 

It  is  necessary  to  distinguish  between  methods  for  physiological 
study  of  gastric  peristalsis  and  methods  for  diagnostic  or  clinical 
work.  Our  method  is  available  mainly  for  the  physiological 
laboratory. 


CHAPTER  IX. 

HEMMETER'S  METHOD  FOR  TESTING  THE  GASTRIC 
PERISTALSIS. 

Theories  Concerning  ilie  Movements  of  the  Ingesta. 

One  of  the  intragastric  stomach-shaped  rubber  bags  wliich  are 
used  in  our  clinic  consists  of  three  separated  compartments  :  one 
filling  out  the  pylorus,  the  second  filling  out  the  middle  portion  of 
the  stomach  (the  fundus),  the  third  occupying  a  small  part  of  the 
fundus  and  the  saccus  ccecus  cardise.  (See  N.  V.  Med.  Jour. ^  Sat., 
June  22,  1895,  p.  772,  and  the  accompanying  illustration.)  Each 
one  of  these  compartments  records  on  the  kymograph  by  a 
separate  tambour. 

In  the  report  referred  to  we  made  the  assertion,  from  the  results 
obtained  with  this  bag,  that  in  the  human  being  most,  if  not  all,  of 
the  peristaltic  waves  are  executed  by  and  start  at  the  pyloric  end. 
This  statement  was  made  before  Moritz's  investigations  were  pub- 
lished in  the  Zeitsclirift  filr  Biologie,  proving  that  the  cardiac  end 
and  the  fundus  of  the  stomach  could  not  contract,  even  when 
stimulated  by  powerful  faradic  currents  on  both  the  mucous  and 
peritoneal  surfaces. 

One  week  before  our  results  were  published  in  the  New  York 
Medical  Jonrnal^  Dr.  S.  J.  IMeltzer,  of  New  York,  published  his 
results  with  direct  and  indirect  faradization  of  the  digestive  canal, 
which  demonstrated  quite  conclusively  that  the  mucous  membrane 
of  the  digestive  canal  offers  a  considerable  resistance  to  the  penetra- 
tion of  the  faradic  current  to  the  muscular  coat,  the  greatest  resist- 
ance being  found  in  the  mucous  membrane  of  the  stomach. 
Percutaneous  and  direct  faradization  of  the  stomach  or  intes- 
tines can  not  produce  any  contraction  in  these  parts. 

IMeltzer  stated  explicitly  the  kind  of  instruments  used, — the 
sliding  inductorium  (Schlittenapparat)  of  DuBois  Reymond,  a 
Grove's  cell  prepared  anew  for  each  experiment, — and  also  the 
distance,  in  every  case,  of  the  primary  from  the  secondary  coil. 
His   device   of  including    the   sciatic   nerve   of  an  animal    (nerve- 

80 


ELECTRIC    STIMULATION    OF    GASTRIC    MUSCLE. 


8l 


muscle   preparation  of  hind  leg  of  frog,  most  likely)  in  the  circuit 
is  practical,  and  has  for  a  long  time  been  used  in  our  laboratory. 

There  is,  however,  a  very  important  matter  which  physiologists 
must  insist  on  knowing,  and  which  Meltzer  does  not  state,  per- 
haps because   it  was   not   very  readily  found  out ;   and  that  is,  the 


Fig.  7. — Intragastric  Tissue  Rubber  Bag,  with  three  distinct  parts  and  three  separate  outlets  for 
recording  the  origin  and  direction  of  gastric  peristalsis.  Outside  of  the  mouth  the  triple  tube 
separates  into  its  three  component  tubes,  each  being  connected  with  a  separate  tambour  and  glass 
ink  pen,  writing  the  gastric  contractions  and  relaxations  on  the  kymograph.  Part  No.  i  records 
the  contraction  of  the  pylorus  ;  part  No.  2,  the  middle  of  the  stomach  ;  and  part  No.  3,  of  the  cardiac 
end. 


number  of  stimulations  to  the  second  used  b\'  him.  Involuntary 
muscle-fibers  are  much  slower  to  contract  than  voluntary  muscles, 
and  in  electrical  stimulation  experiments  they  contract  much  more 
readily  when  the  number  of  stimulations  does  not  exceed  240  per 


82  METHODS    FOR    TESTING    THE    GASTRIC    PERISTALSIS. 

minute.     The  best  contractions  are  obtained  at  a  much  lower  rate 
of  stimulation. 

The  vibrator  on  the  DuBois  Reymond  inductorium  was  found, 
after  months  of  experimentation,  to  send  too  many  stimulations 
into  the  gastric  muscle  per  second.  Later  on,  when  we  used  the 
Kronecker  interrupter,  in  connection  with  a  Jacquet  chronograph, 
and  no  more  than  lOO  stimulations  per  minute,  it  was  found  that 
the  preantral  sphincter  could  be  made  to  contract  with  the  distance 
of  primary  from  the  secondary  coil,  =  O,  and  both  electrodes  on 
the  mucosa. 

To  get  this  result,  it  is  best  to  make  the  animal  starve  for  twelve 
hours,  as  for  some  reason  yet  unknown  the  contractions  are  more 
unlikely  to  occur  the  sooner  the  experiment  is  made  after  the  in- 
gestion of  food.  Still,  it  must  be  emphasized  that  the  mucosa  of 
the  stomach  is  practically  a  non-conductor.  We  had  occasion  to 
try  this  in  the  physiological  laboratory  recently,  with  a  bit  of 
healthy  human  stomach-mucosa  which  one  of  our  students  tore 
off  from  the  wall  of  his  stomach  during  experimental  lavage;  the 
piece  was  15  mm.  long,  five  to  six  mm.  broad,  and  two  to  four  mm. 
thick.  The  gentleman  in  question,  after  trying  to  wash  his  stomach 
out,  and  not  succeeding  to  his  satisfaction,  connected  the  end  of 
the  tube  with  a  suction  apparatus  (aspirator). 

This  was  followed  by  copious  hematemesis,  for  which  we  were 
hastily  summoned.  In  the  stomach-tube,  partly  projecting  from 
the  lower  opening,  was  a  bit  of  fleshy  substance,  which,  on  micro- 
scopic examination,  proved  to  be  gastric  mucosa.  After  the 
hemorrhage  ceased,  the  young  man  was  treated  for  one  week  as  if 
he  had  gastric  ulcer.  He  did  not  experience  any  pain  during  the 
accident,  nor  thereafter;  the  only  thing  that  frightened  him  was 
the  blood.  He  made  a  good  recovery.  This  bit  of  mucosa  was 
placed  in  a  continuous  circuit  generated  by  a  battery  of  three 
freshly  prepared  Grove's  cells,  with  a  milliamperemeter,  soon  after 
it  was  found  ;  the  meter  showed  but  three  milliamperes.  As  it  was 
impossible  to  get  this  fresh  piece  of  mucosa  into  the  circuit  perfectly 
dry,  it  is  probable  that  the  indication  of  three  milliamperes  was 
brought  about  through  the  conducting  agency  of  the  moisture  on 
the  outside  of  the  tissue. 

In  the  biological  laboratory  of  the  Johns  Hopkins  University 
we  have  frequently  had  persons'  stomachs  connected  with  the 
kymograph,  and  an  intragastric   rubber  bag  blown   up  to  fill  out 


RESISTANCE    OF    MUCOSA    TO    ELECTRIC    STIMULATION.  83 

their  stomachs  exactly.  Through  the  intragastric  bag  ran  two 
insulated  wires,  one  ending  in  a  small  brass  knob  near  the  pylorus, 
the  other  coming  out  against  the  mucosa  near  the  cardia  in  a 
similar  knob. 

Every  active  and  passive  motion  was  recorded  by  a  manometer 
pen  [N.  Y.  Med.  Jour.,  June  22,  1895,  p.  771).  But  the  strongest 
faradic  currents  (distance  of  primary  from  secondary  coil  =  o) 
could  produce  no  contractions  of  the  stomach. 

Dr.  George  P.  Dreyer  and  myself  held  one  of  the  poles  in  the 
right  hand — the  plus,  for  instance — while  the  negative  was  in  the 
stomach  ;  with  the  left  hand  we  touched  the  back  of  the  person's 
neck.  The  current  was  so  strong  that  it  became  intolerable  to  us. 
Although  this  current  made  its  circuit  through  the  patient's  stomach, 
it  caused  no  contraction,  as  was  evidenced  by  the  manometer  in 
connection  with  the  intragastric  bag. 

Frequently  we  could  observe  contractions  of  any  skeletal  muscle 
upon  which  the  outer  electrode  was  placed, — for  instance,  the  gas- 
trocnemius,— and  still  the  stomach  did  not  contract.  This  proves  that 
in  some  conditions  the  gastric  mucosa  may  transmit  a  current,  yet 
the  muscular  layer  give  no  evidence  of  contractions.  We  do  not 
wish  to  imply  that  it  is  absolutely  impossible  to  contract  the  human 
stomach  by  electrical  stimulation  ;  but  the  current  required  to  effect 
this  must  be  so  strong  that  the  experiment  becomes  hazardous. 

Einhorn  ("  Diseases  of  the  Stomach,"  pages  78-83)  and  Paul 
Cohnheim  [Archiv  f.  Verdatiungskrankheiten,  Bd.  i,  S.  274)  have 
described  tiny  bits  of  mucosa  which  are  found  in  the  wash-water 
and  vomit  of  many  gastric  sufferers.  We  can  confirm  this  obser- 
vation, and  add  that  we  have  found  these  pieces  of  gastric  mucosa 
on  washing  out  the  stomachs  of  perfectly  healthy  persons. 

Now,  it  has  occurred  to  us  that  in  rare  instances  in  which  a  good 
contraction  of  the  stomach  was  obtained,  it  was  due  to  the  fact 
that  the  current  found  its  way  to  the  muscular  layer,  through  spots 
from  which  the  glandular  layer  had  been  cast  off.  It  must  not  be 
omitted  that  all  stomachs  experimented  upon  by  our  method  in 
this  series  were  washed  out  prior  to  the  experiment  to  insure 
absence  of  current-interrupting  food-particles  in  the  organ. 

Professor  Moritz,  of  the  University  of  Munich,  experimented 
with  an  apparatus  very  similar  to  ours,  except  that  his  rubber 
intragastric  bag  was  round,  not  stomach-shaped.  It  did  not,  there- 
fore, exactly  and  completely  fill  out  the  organ,  nor  did  he  use  the 


84  METHODS    FOR    TESTING    THE    GASTRIC    PERISTALSIS. 

graduated  pressure  bottles,  by  which  it  is  possible  to  determine 
exactly  how  much  air  is  blown  into  the  bag.  Instead  of  a 
pneumograph,  he  used  a  cork  in  one  nostril  of  the  patient,  which 
was  connected  with  a  second  manometer,  writing  on  the  Ludwig 
kymograph.  The  advantage  of  the  pneumograph  over  this  method 
must  be  apparent  to  every  one. 

The  author's  first  results  appeared  in  print  three  months  before 
those  of  Moritz  in  the  Zeitschrift  fur  Biologic,  Bd.  xxxii,  which  are 
perhaps  the  most  important  contributions  to  the  physiology  of 
the  motor  function  since  the  investigations  of  Hofmeister  and 
Schiitz  {Archivf.  exper.  Pathol,  und  Pharm.,  1886,  Bd.  xx).  In  order 
that  the  mechanism  of  the  gastric  peristalsis  may  be  better  under- 
stood, it  is  well  to  bear  in  mind  the  arrangement  of  the  muscular  lay- 
ers,—(i)  longitudinal,  (2)  oblique,  and  (3)  circular.^and  what  was 
said  under  the  head  of  anatomy  of  the  gastric  layers  and  the  forma- 
tion of  the  sphincter  of  the  pylorus.  The  part  of  the  stomach  near 
the  pyloric  end  is  spoken  of  more  specifically  as  the  antrum  pylori. 

The  line  of  separation  between  the  antrum  pylori  and  the  body 
or  fundus  of  the  stomach  is  made  by  a  special  thickening  of  the 
circular  fibers,  forming  what  is  spoken  of  as  the  transverse  band  by 
older  writers, — for  instance,  Beaumont,  in  his  "  Physiology  of 
Digestion,"  second  edition,  1847,  page  104.  (A  pioneer  piece  of 
work,  very  fundamental  and  thorough  in  its  observations,  this 
book  remains  a  monument  to  American  physiological  investigation.) 
Recent  observers  describe  this  transverse  band  as  the  sphincter 
antri  pylorici,  and  locate  it  at  a  distance  of  seven  to  ten  cm.  from 
the  pylorus. 

In  the  antrum  pylori  there  is  a  very  strong  musculature,  and 
its  glands  contain  only  (or  rather  mostly)  chief,  central,  or  ferment 
cells.  The  exact  character  of  the  gastric  movements  during 
digestion  were  first  carefully  studied  on  the  human  being  by 
Beaumont ;  his  facts  and  errors  have  influenced  physiologists 
more  or  less  up  to  the  present  time.  One  can  not  fail  to  suspect 
that  the  stomach  of  Alexis  St.  Martin  and  its  manner  of  peristalsis 
were  too  far  from  the  normal  to  permit  absolutely  correct  con- 
clusions. The  extensive  adhesions  which  Beaumont  describes 
certainly  acted  at  times  as  irritants,  at  others  as  impediments,  to 
normal  peristalsis. 

Professor  W.  H.  Howell's  views  on  the  gastric  movements,  as 
expressed  in  his  new  "  American  Text-book  of  Physiology,"  page 


Beaumont's  views  on  gastric  peristalsis.  85 

317,  will  serve  as  an  expression  of  a  modern  specialist  in  this 
branch.  He  says  {loc.  cit.)  the  movements  occur  in  two  phases  : 
"  first,  the  feeble  peristaltic  movement  running  over  the  fundus, 
chiefly  on  the  side  of  the  great  curvature,  and  resulting  in  pushing 
the  fundic  contents  into  the  antrum  ;  secondly,  the  sharp  contrac- 
tion of  the  sphincter  antri  pylorici,  followed  by  a  similar  contraction 
of  the  entire  musculature  of  the  antrum,  both  circular  and  longi- 
tudinal, the  effect  of  which  is  to  squeeze  some  of  the  contents  into 
the  duodenum." 

"  It  is  possible  that  either  of  these  phases,  especially  the  first, 
might  occur  at  times  without  the  other,  and  in  the  first  phase  it  is 
possible  that  the  longitudinal  fibers  of  the  stomach  also  contract, 
shortening  the  organ  in  its  long  diameter,  and  aiding  the  propulsive 
movement,  but  actual  observation  of  this  factor  has  not  been  suc- 
cessfully made.  It  can  well  be  understood  that  a  series  of  these 
movements  occurring  at  short  intervals  would  result  in  putting  the 
entire  semi-liquid  contents  of  the  stomach  into  constant  circulation." 

"  The  precise  direction  of  the  current  set  up  is  not  agreed  upon, 
while  it  is  probable  that  the  graphic  description  given  by  Beaumont 
is  substantially  accurate.  A  portion  of  this  description  may  be 
quoted  as  follows  :  The  ordinary  course  and  direction  of  the  revo- 
lutions of  food  are,  first,  after  passing  the  esophageal  ring,  from, 
right  to  left,  along  the  small  arch  ;  thence,  through  the  large 
curvature,  from  left  to  right.  The  bolus,  as  it  enters  the  cardia, 
turns  to  the  left,  passes  the  aperture,  descends  into  the  splenic 
extremity,  and  follows  the  great  curvature  into  the  pyloric  end  ;  it 
then  returns  in  the  course  of  the  small  curvature." 

"  The  average  time  taken  for  one  of  these  complete  revolutions, 
according  to  observations  made  by  Beaumont,  seems  to  vary  from 
one  to  three  minutes." 

"  It  is  possible,  of  course,  that  this  typical  circuit  taken  by  food 
may  often  be  varied,  more  or  less,  by  different  conditions,  but  the 
muscular  movements  observed  from  the  outside  would  seem  to  be 
adapted  to  keeping  up  a  general  revolution  of  the  kind  described. 
The  general  result  upon  the  food  may  be  easily  imagined.  It  be- 
comes thoroughly  mixed  with  the  gastric  juice  and  any  liquid 
which  may  have  been  swallowed,  and  is  gradually  disintegrated, 
dissolved  and  more  or  less  completely  digested,  so  far  as  the  pro- 
teid  and  albuminoid  constituents  are  concerned." 

"  The  mixing  actions  are  aided,  moreover,  by  the  movements  of 


86  METHODS    FOR    TESTING    THE    GASTRIC    PERISTALSIS. 

the  diaphragm  in  respiration,  since  at  each  descent  it  presses  upon 
the  stomach.  The  powerful  muscular  contractions  of  the  antrum 
serve  also  to  triturate  the  softened  solid  particles,  and  finally  the 
whole  mass  is  reduced  to  a  liquid  or  semi-liquid  condition,  in  which 
it  is  known  as  chyme,  and  in  this  condition  the  rhythmic  contrac- 
tion of  the  muscles  of  the  antrum  eject  it  into  the  duodenum." 

"  The  rhythmic  spurting  of  the  contents  of  the  stomach  into  the 
duodenum  has  been  noticed  by  a  number  of  observers,  through 
duodenal  fistulae  in  dogs,  established  just  beyond  the  pylorus.  It 
has  been  shown,  also,  that  when  the  food  is  entirely  liquid — water, 
for  example — the  stomach  is  emptied  in  a  surprisingly  short  time, 
— within  twenty  or  thirty  minutes  ;  if,  however,  the  water  is  taken 
with  solid  food,  then,  naturally,  the  time  it  will  remain  in  the 
stomach  may  be  much  lengthened." 

Brinton  ("  Diseases  of  the  Stomach  ")  advanced  the  view,  which 
differs  from  Beaumont's,  in  assuming  a  central  current  of  the  food, 
moving  from  the  pylorus  to  the  cardia  through  the  central  long 
axis  of  the  stomach.  There  are,  according  to  this  author,  two  cur- 
rents, one  along  each  curvature  running  from  the  cardia  to  the 
pylorus,  meeting  and  turning  inward  toward  the  center  of  the 
stomach  in  front  of  the  pylorus,  and  then  running  back  toward  the 
esophagus  as  a  single  central  current,  there  dividing  to  make 
again  two  currents  as  before,  one  along  each  curvature. 

According  to  Poensgen  ("  Die  motor.  Verricht.  des  menschl. 
Magens,"  Strassburg,  S.  82),  Reymond,  Donders,  and  Lesshaft  ap- 
proved of  this  theory;  while  Penzoldt  and  Foster  accept  the  great 
food-circle  of  Beaumont. 

Although  we  have  made  over  fifty  experiments  on  dogs,  cats,  and 
rabbits  to  observe  a  food-circulation  within  the  stomach  corre- 
sponding to  these  views,  and  although  we  have  had  an  opportunity 
of  seeing  into  the  human  stomach,  through  fistulse,  during  diges- 
tion, we  have  not  been  able  to  confirm,  by  actual  observation,  either 
Beaumont's  or  Brinton's  views.  While  we  have  no  new  explana- 
tions to  ofiTer,  it  has  occurred  to  us  that  the  piston-like  backward 
and  forward  movements  of  the  food  caused  by  the  antral  contrac- 
tions, and  especially  of  the  sphincter  of  the  antrum,  is  a  sufficient 
force  to  effect  the  mixture  of  the  chyme  with  HCl  and  the  fer- 
ments such  as  is  found  in  it  when  it  leaves  through  the  pylorus. 

The  views  of  Beaumont  and  Brinton  date  from  the  epoch  when 
it  was  considered  all-important  that  food  must  be  properly  digested 


CRITICISM    OF    THE    THEORIES    OF    BEAUMONT    AND    BRINTON.      8/ 

and  macerated  in  the  stomach;  it  was  not  conceivable  then  that  by 
far  the  main  bulk  of  digestion  is  carried  on  in  the  intestines.  Hence 
the  complicated  theories  of  Beaumont  and  Brinton,  of  circular 
movements  of  food,  owe  their  origin  to  the  thought  that  such  a 
movement  was  necessary  to  mix  the  ingesta  with  the  gastric  juice. 
In  dogs  this  mixture  is  not  proven  to  occur  in  every  instance.  In 
herbivora  (horse,  cow),  the  center  of  the  food  mass  in  the  stomach 
may  be  alkaline  or  neutral  in  animals  killed  one  hour  and  a  quarter 
after  feeding. 

The  almost  vertical  position  of  the  stomach  was  unknown  to 
Beaumont  and  Brinton.  Like  many  clinicians  of  the  day,  they 
believed  the  organ  was  normally  in  a  horizontal  position,  trans- 
versely across  the  upper  part  of  the  abdomen.  The  amount  of 
force  required  to  lift  the  food-mass  in  a  vertical  line  upward  is 
considerable ;  it  is  necessary  to  imagine  a  still  greater  force  to 
accomplish  the  vertical  ascent  on  the  side  of  the  lesser  curvature, 
in  order  to  conceive  of  a  simultaneous  descent  on  the  side  of  the 
great  curvature,  which  descending  current  must  inevitably  interfere 
more  or  less  with  the  ascending  one. 

In  a  number  of  experiments  in  which  the  stomachs  of  animals 
on  opening  the  abdomen  were  found  in  active  motion,  we  inserted 
long  needles  through  the  gastric  walls  to  determine  the  direction 
they  would  assume  under  the  pressure  of  the  ingesta ;  according 
to  Beaumont,  the  ingesta  moving  from  the  saccus  ccecus  along 
the  greater  curvature  to  the  pylorus  should  compel  the  points  of 
needles  to  be  directed  toward  the  pylorus  when  run  through  the 
greater  curvature,  and  along  the  lesser  curvature  they  should 
point  toward  the  cardia. 

If  Brinton's  theory  were  true,  the  points  of  the  needles  at  both 
curvatures  should,  at  least  during  a  large  period  of  gastric  diges- 
tion, be  directed  toward  the  pyloric  end.  If  needles  are  inserted  to 
a  distance  of  yi  of  an  inch  along  both  curvatures  during  active 
gastric  peristalsis,  a  great  diversity  of  movements  of  the  outside  por- 
tions of  the  needles  is  observable.  They  very  rarely  point  the 
same  way  along  either  curvature,  and  one  portion  of  them  may 
point  toward  the  cardia,  while  another  points  to  the  pylorus.  Only 
when  the  needles  are  inserted  very  deep,  so  that  they  dip  into  the 
central  or  axial  stream,  can  one  occasionally  observe  what  appears 
as  concerted  action. 

During  active  peristalsis,  when  the  pre-antral  sphincter  at  times 


88  METHODS    FOR    TESTING    THE    GASTRIC    PERISTALSIS. 

contracts  so  powerfully  as  almost  to  obliterate  the  lumen,  those 
needles  inserted  into  the  fundic  portion  of  both  the  greater  and 
lesser  curvatures  are  strongly  turned  toward  the  cardia,  but  simul- 
taneously those  few  needles  in  the  antral  and  pyloric  portions  are 
turned  toward  the  duodenum.  The  same  evidence  of  a  central  or 
axial  current,  which  indicates  the  pumping  work  of  the  muscular 
antrum  in  pushing  back  solid  particles  into  the  fundus,  and  squeez- 
ing liquid  and  semi-liquid  portions  into  the  duodenum,  can  be 
obtained  by  the  intragastric  electric  lamp  when  introduced  during 
the  height  of  gastric  digestion.  These  lamps  can  be  seen  through 
the  abdominal  wall  in  dogs  whose  abdomens  have  been  shaven, 
when  introduced  in  a  dark  room,  though  naturally  not  quite  so 
distinct  as  when  the  abdomen  is  opened. 

Once  we  observed  this  axial  food-current  at  the  clinic  in  a  female 
patient  with  very  thin  abdominal  parietes,  when  the  Einhorn  intra- 
gastric lamp  was  introduced  one  hour  after  a  meal.  In  animals 
with  abdomen  opened  we  have  been  able  to  see  this  lamp  carried 
along  the  entire  greater  curvature,  from  the  pylorus  toward  the 
cardia,  during  active  digestion,  but  the  occurrence  is  so  rare  as  to 
appear  accidental. 

That  the  retrogressive  current,  which  is  set  up  by  contractions 
of  the  antrum  forcing  the  too  solid  food-particles  back  toward  the 
fundus,  must  inevitably  set  up  some  new  movements  among  the 
remaining  food-mass  in  the  fundic  end  is  natural,  but  we  doubt 
whether  it  ever  reaches  that  systematic  circulation  described  first 
by  Beaumont  and  Brinton. 

It  should  not  be  overlooked  that  if  the  observations  of  Beaumont 
of  a  complete  food-circuit  were  really  true  and  constituted  the  only 
movements  in  addition  to  the  duodenal  extrusion  which  the  food- 
mass  underwent,  there  must  always  be  a  mass  of  food  in  the 
center  of  the  stomach  which  never  touches  the  gastric  wall  ;  if  all 
the  food  moves  about  along  the  periphery,  there  must  be  a  central, 
quiet  portion. 

Brinton  was  aware  of  this  defect  in  Beaumont's  statements,  and 
improved  upon  them  by  his  still  more  complicated  theory  of  piston 
movements  to  explain  the  axial  food-motions. 

If  the  conditions  described  by  these  authors  exist,  they  are  not 
well  explained  by  the  arrangement  of  the  muscularis  of  the  fundus, 
which,  as  far  as  the  work  of  Meltzer  [loc.  cit),  Moritz  {loc.  cit.),  and 
Goldschmidt  {loc.  cit.)  show,  is  very  feeble  indeed  in  its  contrac- 


INTRAGASTRIC     PRESSURE.  89 

tions  and  hardly  sufficient  to  propel  food  in  any  direction  ;  yet, 
according  to  the  above  theory,  much  work  is  ascribed  to  it,  but  as 
the  pre-antral  sphincter  is  only  seven  to  eight  cm.  from  the  pylorus 
it  certainly  can  not  be  made  accountable  for  the  mo\"ements  all 
around  the  cardia  and  the  saccus  coecus. 

The  musculature  of  the  fundic  end  has  never  been  observed  in 
peristaltic  motion  by  us,  excepting  the  peristalsis  occasionally 
arising  from  the  antrum  and  traveling  upward  over  it.  During 
active  peristalsis  it  is  in  a  condition  of  tonic  contraction  with  the 
intragastric  bag  in  the  fundus  ;  we  have  estimated  this  to  be  equal 
to  six  to  eight  cm.  of  water  (water  manometer). 

Moritz,  in  his  work  on  "  The  ]\Iotor  Function  of  the  Stomach," 
studiously  avoids  referring  to  any  systematic  food-circulation  within 
the  organ.  It  seems  rational  that  sufficient  churning  and  mixing 
is  effected  by  the  powerful  contractions  of  the  antrum  during  the 
general  tonus  of  the  fundus  to  explain  the  saturation  and  softening 
of  the  ingesta  by  gastric  juice. 

The  contrasting  relations  of  the  fundus  and  antrum  regarding 
active  peristalsis  are  evident  in  the  degree  of  pressure,  as  observed 
on  a  water  manometer  in  connection  with  our  triple  intragastric 
bag.  In  the  fundus  the  pressure  is,  on  an  average,  equal  to  three 
to  six  cm.  of  water.  The  increase  of  intragastric  pressure  due  to 
cardiac  action  is  equal  to  one  to  two  cm.  (In  this  is  included  the 
pressure  due  to  every  new  heart  impulse  and  aortic  impulse.)  The 
inspiratory  increase  of  pressure  is  equal  to  6  to  12  cm.  These  are 
very  nearh' the  figures  Professor  Aloritz  obtained,  and  we  add  them 
here  as  merely  in  support,  and  confirmatory,  of  his  views. 

The  physiology  of  the  motor  function  has  been  dwelt  upon  more 
extensively  than  seems  necessary  in  a  condensed  statement  of 
gastric  patholog}",  not  only  because  it  is  the  most  important  office 
of  the  stomach,  but  because  we  have  become  convinced  that,  in  a 
large  majority  of  disorders  of  secretion  and  absorption, — not  all, — 
an  abnormality  in  the  motor  function  lies  at  the  foundation. 

The  exaggerated  or  diminished  peristalsis  can  on  careful  exam- 
ination be  detected  sometimes  before  the  secretory  and  absorptive 
anomalies  are  apparent.  The  secretory  disturbances  observed  after 
double  vagotomy  (section  of  both  vagi)  are  due.  according  to 
Contejean,  to  the  motor  paralysis  caused  at  the  same  time 
{^Ardiiv.  de  Physiologie,  vol.  iv,  p.  640).  A  similar  view  is  held  by 
H.  Borutteau  [Pldiigcrs  Archiv,  Bd.  lxv,  p.  26). 
7 


go  METHODS    FOR    TESTING    THE    GASTRIC    PERISTALSIS. 

The  relation  between  motility  and  secretion  and  absorption  is  not 
at  all  well  understood;  the  peristaltic  movements  effecting  a  churn- 
ing motion  are  those  mostly  concerned  in  stimulating  secretion  ; 
when  these  movements  are  lost,  secretion  is  generally  lost  also. 

The  last  vestige  of  peristalsis  left  is  that  by  which  the  stomach 
is  emptied,  and  it  may  be  present  with  total  absence  of  secretion. 
In  stomachs  with  motility  much  impaired  and  secretion  arrested, 
the  absorptive  function  is  greatly  reduced  (atrophic  gastritis,  car- 
cinoma). In  temporary  arrest  of  these  functions,  the  secretive  and 
absorptive  functions  generally  return  with  improved  motility. 

In  our  drawing  (frontispiece),  the  manner  in  which  the  deep  ends 
of  the  fundus  glands  are  encircled  by  fibers  from  the  muscularis 
mucosae  is  very  evident.  From  this  it  is  conceivable  that  the  func- 
tion of  the  gland-cells  is  in  a  manner  dependent  upon  the  con- 
tractility of  the  fibers  of  the  muscularis  mucosae,  which  can  not 
fail  to  influence  the  blood-supply  to  these  cells  (see  Mall,  on 
"Circulation  in  the  Dog's  Stomach,"  chap.  i). 


CHAPTER  X. 

ABSORPTION  FROM  THE  STOMACH. 

Penzoldt's  and Faber's,  Herschers,  Julius  Miller's,  and  Heninieter''s 
Tests  for  Gastric  Resorption. 

The  method  most  commonly  employed  to  test  gastric  resorption 
is  that  of  Penzoldt  and  Faber,  consisting  of  three  to  five  gr.  of  iodid 
of  potassium  inclosed  in  a  gelatin  capsule,  which  is  administered 
with  lOO  c.c. — 3^  ounces — of  water.  Iodid  of  sodium  or  potas- 
sium, when  taken  internally,  will  appear,  and  can  be  tested  for  in 
the  saliva  and  in  the  urine,  where  it  is  excreted  in  from  six  and 
one-half  to  fifteen  minutes. 

The  test  is  generally  made  by  wetting  starch  paper  with  the  saliva 
of  the  patient  every  two  minutes  after  the  KI  is  taken,  and  touching 
the  wet  spot  with  fuming  nitric  acid.  The  first  appearance  of  a 
blue  color  indicates  that  the  iodid  has  reached  the  point  of  excre- 
tion, and  consequently  must  have  been  absorbed.  If  this  reaction 
occurs  later  than  after  fifteen  minutes,  then  the  rate  of  absorption 
is  reduced.  This,  according  to  Zweifel  ("  Resorpt.  Verhaltnisse  d. 
menschl.  Magens,"  Dentsch.  Arch.  f.  klin.  Med.,  Leipzig,  Bd.  xxxix, 
p.  349,  1886),  occurs  in  gastritis,  dilatation,  and  carcinoma;  in 
gastric  ulcer  the  resorption  is  said  to  be  normal,  or  nearly  so. 

Most  authorities  (J.  Wolff,  Zweifel,  Sticker,  Quetsch)  differ  very 
much  on  this  question,  but  agree  on  the  reduced  absorption  in 
carcinoma.  If  the  iodid  is  given  during  a  meal,  the  reaction  occurs 
much  later. 

Herschel  ("Indigestion,"  London,  1895,  p.  115)  estimates  the 
absorptive  power  by  giving  two  decigrams  of  powdered  rhubarb, 
which  gives  a  red  color  in  the  urine  with  liquor  potassae  normally 
in  fifteen  minutes.  Our  experience  with  this  method  is  that 
frequently  the  urine  is  so  highly  colored  in  digestive  diseases 
that  the  red  color  must  be  very  decided  to  be  recognized, — in 
addition  to  which  it  suffers  from  the  same  objection  as  Penzoldt's 
and  Faber's  method.     In  the  first  place,  Brandl's  experiments  have 

91 


92  ABSORPTION    FROM    THE    STOMACH. 

shown  that  sodium  iodid  is  absorbed  to  a  very  slight  degree  or  not 
at  all  in  dilute  solutions. 

Not  until  its  solutions  reach  a  concentration  of  three  per  cent, 
or  more  does  its  absorption  become  important.  Accordingly,  all 
soluble  inorganic  salts  are  practically  not  absorbed  in  the  stomach, 
since  it  can  not  be  supposed  that  they  are  normally  swallowed  in 
solutions  so  concentrated  as  three  per  cent.  Brandl  also  found 
that  condiments,  such  as  mustard  and  pepper,  and  also  alcohol, 
very  much  facilitated  the  absorption  of  sodium  iodid.  Perhaps 
these  substances  act  by  stimulating  the  epithelial  cells,  or  by 
causing  a  marked  hyperemia  of  the  mucosa. 

The  absorption  time  does  not  vary  much  in  the  same  individual, 
except  when  the  stomach  is  full ;  in  this  case  it  is  not  only  pro- 
longed, but  is  very  variable  in  the  same  individual.  This  prolon- 
gation, according  to  Sidney  Martin  ("  Diseases  of  the  Stomach," 
London,  1895),  is  probably  due  to  a  considerable  dilution  of  the 
iodid  by  the  stomach  contents,  and  also  to  the  fact  that  the  salivary 
glands  are  not  so  active  after  a  meal  as  in  the  fasting  condition. 
One  must  not  overlook  the  fact  in  these  experiments  that  it  is  not 
only  the  absorptive  activity  of  the  stomach  that  is  being  investi- 
gated, but  also  the  excretory  activity  of  the  salivary  glands. 

In  Zweifel's  experiments  it  is  probable,  from  what  we  know  of 
the  absorption  of  water  in  the  stomach,  through  the  observations 
of  Tappeiner  ("  Ueber  Resorption  im  Magen,"  Zeitschr.  f.  Biol., 
Miinchen,  Bd.  xvi,  p.  497,  1881)  and  von  Mering  (/^r.  «V.),— that 
most  of  the  liquid  containing  the  iodid  passes  rapidly  into  the  duo- 
denum. Therefore  we  may  be  testing  not  only  gastric  absorption 
and  excretory  activity  of  salivary  glands,  but  also  intestinal 
absorption. 

Zweifel  concludes  (Joe.  cit?)  that  in  all  diseases  of  the  stomach 
there  is  a  prolongation  of  absorption  time,  which  is  greatest  in  dila- 
tation and  carcinoma  and  least  in  chronic  gastric  catarrh,  and  very 
slight  in  ulcer  in  the  later  stages  ;  in  the  early  stages  of  ulcer,  how- 
ever, he  claims,  the  rate  of  absorption  is  also  prolonged. 

It  is  very  evident  that  no  differentiation  between  catarrh  and 
ulcer  is  possible  according  to  this  method,  and  thereby  one  of  the 
main  purposes  of  such  investigations — that  of  aiding  in  the  estab- 
lishment of  a  diagnosis — is  thwarted. 

In  view  of  these  defects,  which  apply  equally  well  to  Herschel's, 
Penzoldt's   and   Faber's    methods   of  testing    absorption,  and    are 


HEMMETERS    METHOD    FOR    TESTING    ABSORPTION.  93 

caused  mainly  by  the  fact  that  water  is  not  absorbed  from  the 
stomach,  and  that  the  varying  secretory  activity  of  the  sahvary 
glands  is  a  factor  influencing  absorption  time,  we  have  devised  a 
method  which  is  available  for  experiments  on  gastric  absorption  in 
the  physiological  laboratory,  and  which  we  have  successfully  tried 
on  six  male  and  eight  female  patients  and  ten  healthy  students. 
The  methods  of  testing  the  urine  and  saliva  were  discarded  entirely. 

Our  method  consists  in  washing  out  the  stomach  thoroughly; 
then,  by  means  of  our  method  of  duodenal  intubation,  the  entrance 
into  the  duodenum  was  plugged,  or  closed  up,  by  introducing  a 
small  rubber  baloon  into  it  and  blowing  it  up  just  in  front  of  or 
beyond  the  pylorus.  (This  method  has  been  described  after  the 
author's  publication  by  Dr.  F.  Kuhn  in  the  Mi'incJiener  Medizin. 
Wochenschr.,  Nos.  27,  28,  and  29,  1896,  but  his  method  is  founded 
upon  a  different  principle  from  ours — the  spiral  electrode.) 

After  thus- mechanically  closing  the  pylorus,  a  weighed  amount 
of  any  harmless  inorganic  salt, — sodium  chlorid  or  sodium  phos- 
phate,— dissolved  in  100  c.c.  of  distilled  water  so  as  to  make  a  three 
per  cent,  solution,  is  poured  into  the  organ  through  a  tube;  this  is 
indispensable  to  exclude  loss  of  the  salt  solution  through  clinging 
to  the  tongue,  mouth,  and  esophagus,  or  absorption  from  these 
tissues. 

After  a  lapse  of  ten  minutes  the  fluid  is  again  drawn  out  of  the 
stomach  by  aspiration,  or  even,  if  necessary,  by  adding  known 
quantities  of  distilled  water,  until  the  last  washing  gives  no  indica- 
tion of  containing  any  trace  of  the  salt  by  a  proper  chemical  test. 
(In  case  XaCl — sodium  chlorid,  or  common  cooking  salt — has  been 
used,  a  weak  solution  of  nitrate  of  silver  (AgXOg)  can  be  employed 
to  assure  oneself  that  this  last  washwater  contains  no  more  NaCl. 
The  normal  HCl  is  not  secreted  so  rapidly  as  to  cause  confusion 
in  the  result.)  This  entire  water  is  now  evaporated  to  dryness  and 
the  residue  weighed.  The  difference  between  the  amount  of  NaCl 
poured  into  the  stomach — which  in  a  three  per  cent,  solution  is 
three  gm.  in  case  100  c.c.  are  used — and  the  amount  regained  indi- 
cates the  degree  of  gastric  absorption. 

To  simplify  matters,  the  practical  suggestion  of  Julius  Miller 
(Boas'  Archiv.  f.  Verdauungskrankh.,  Bd.  i,  p.  237,  "Zur  Kennt. 
d.  Sek.  u.  Resorpt.  im  menschl.  Magen")  has  been  utilized  and 
can  be  recommended.  It  consists  in  noting  the  specific  gravity 
of  salt  solutions  before  pouring  them  through  the  tube,  and,  after 


94  ABSORPTION    FROM    THE    STOMACH. 

any  desired  time,  the  solutions  are  washed  out  or  aspirated,  and 
the  specific  gravity  again  determined. 

The  difference  between  these  specific  gravities  taken  before  the 
salt  solution  enters  the  stomach,  and  after  it  is  regained,  affords  a 
satisfactory  index  of  the  rate  of  absorption  from  the  stomach  if 
escape  of  the  solution  into  the  duodenum  is  prevented.  It  is  not 
necessary  to  evaporate  the  whole  solution  to  dryness  in  case  sodium 
chlorid  or  any  other  harmless  neutral  salt  is  used.  But  after  meas- 
uring the  total  quantity  of  liquid  regained — say,  for  instance,  it 
amounts  to  one  liter  (looo  c.c.) — the  amount  of  NaCl  in  ten  c.c. 
can  be  determined  by  evaporation  in  platinum,  and  the  weight  of 
the  total  remaining  NaCl  calculated  by  multiplying  the  result  by 
100,  or  whatever  the  figure  may  happen  to  be. 

This  method  of  determining  the  rate  of  gastric  absorption  gives 
approximately  accurate  results,  even  without  duodenal  intubation 
and  mechanical  closing  of  the  pylorus,  provided  that  by  several 
preliminary  experiments  the  motility  of  the  patient's  stomach  has 
been  relatively  determined. 

By  observing  how  much  of  500  c.c.  of  water  he  will  pass  into 
the  duodenum  in,  say,  ten  to  twenty  minutes,  this  also  requiring 
the  drawing  out  again  of  what  is  left  of  the  500  c.c.  of  water  that 
were  taken,  von  Mering  {loc.  cit.)  found  that  of  500  c.c.  of  water 
given  through  the  mouth,  to  a  large  dog,  the  entire  amount,  or  at 
least  495  c.c,  had  been  passed  out  of  the  stomach  through  a 
duodenal  fistula  within  twenty-five  minutes. 

In  the  human  being  the  passage  of  water  out  of  the  stomach  is 
not  nearly  so  rapid.  Julius  Miller  {Joe.  cit.)  found  that  the  human 
stomach  was  not  even  rid  of  200  c.c.  NaCl  solution  of  the  specific 
gravity  1028  in  thirty  minutes;  after  this  time  he  regained  in  one 
case  75  c.c. ;  sometimes  he  regained  more  liquid  than  he  poured  in. 

In  30  tabulated  measurements  which  he  gives  with  sodium 
chlorid  solution  (p.  240,  loc.  cit),  he  regained  more  than  he 
poured  in,  five  times,  the  same  amount  once,  and  a  less  quantity 
25  times.  But  his  figures  go  to  prove  that  even  with  an  open 
passage  into  the  duodenum  comparatively  small  amounts  of  salt 
solutions  are  passed  out  in  fifteen  minutes. 

Hence,  if  in  any  individual  the  average  amount  passing  into  the 
duodenum  in  fifteen  minutes  is  known  by  previous  experiments, 
the  closing  of  the  pylorus  is  not  necessary  to  reach  an  approximate 
result   concerning    the  rate    of  absorption.     Miller  confirms    von 


AUTHOR  S    METHOD    OF    TESTING    ABSORPTION.  95 

Mering's  conclusions,  that,  contemporaneous  with  absorption,  a 
secretion  of  water  occurs  into  the  stomach. 

This  secretion  increases  with  the  concentration  of  the  solutions. 
In  the  five  instances  mentioned  where  more  was  regained  than  was 
poured  in,  the  specific  gravities,  which  are  a  good  indication  of 
concentration,  were  1066,  1061,  1052,  1088,  and  1035.  (Regarding 
the  taste  of  three  per  cent,  solution  of  NaCl,  it  might  be  explained 
that  this  is  the  percentage  of  salt  in  the  water  of  the  Atlantic 
Ocean,  which  has  been  recommended  for  internal  use — A.  Levertin, 
"  Hygieina,"  xlvii,  xlviii.  Svenska  lakaresallsk  Forh.  S.  138, 
1885.) 

In  the  studies  with  occlusion  of  the  pylorus  we  experimented 
also  with  known  solutions  of  sodium  sulphate,  peptone,  maltose, 
cane  sugar,  milk  sugar,  and  alcohol.  As  water  is  poured  out  on 
the  surface  of  the  mucosa,  in  return  for  salts  absorbed,  the  specific 
gravity  will -not  always  instruct  us  as  to  the  contents  of  NaCl, 
which  had  best  be  arrived  at  by  weighing. 

From  experiments  on  animals  it  is  known  that  a  concentrated 
solution  may  cause  the  stomach  to  secrete  water,  thereby  diluting 
it,  but  that  at  the  same  time  it  is  possible  that  there  may  be  no 
resorption,  so  that  weighing  the  residue  from  evaporating  the 
liquid  regained  may  be  unavoidable  for  a  correct  result. 

Maltose  was  found  a  very  practical  substance  for  absorption 
experiments,  though  dextrose  will  also  answer  this  purpose,  as 
their  quantity  can  be  readily  determined  in  solution  by  titration  with 
Fehling's  solution,  and  also  by  the  fermentation  test,  for  which  the 
Einhorn  saccharimeter  is  most  serviceable.  Maltose  will  not 
reduce  as  much  Fehling's  solution  as  dextrose,  the  exact  relation 
between  the  two  being,  according  to  Brown  and  Heron,  for  maltose, 
60.8;  for  dextrose,  100. 

According  to  Soxhlet  one  c.c.  Fehling's  solution  corresponds  to 
7.78  milligrams  =  maltose  in  one  per  cent,  solution  (provided  the 
Fehling's  test  was  not  diluted).  Though  maltose  is  converted 
into  dextrose  in  the  stomach,  the  amount  converted  in  ten  to  fifteen 
minutes  is,  according  to  our  observations,  small  enough  to  be  dis- 
regarded. If  desired,  a  test  by  Barfoed's  reagent  may  be  made  to 
detect  if  any  dextrose  is  present  in  the  liquid  regained. 

The  amount  of  sodium  chlorid  in  the  solution  regained  can  also 
be  determined  by  titration  (Salkowsky  u.  Leube,  "  Die  Lehre 
vom  Harn";  also,  Neubauer  u.  Vogel,  "  Analysen  d.  Urins").     The 


96  ABSORPTION    FROM    THE    STOMACH, 

method  is  given  in  the  laboratory  manual  of  my  assistant,  Dr. 
Edward  L.  Whitney  ("  An  Introduction  into  the  Laboratory 
Methods  of  Clinical  Pathology,"  p.  18,  Baltimore,  1896).  Our 
method  for  absorption  testing  is,  in  brief,  the  following  : 

To  determine  the  amount  of  500  c.c.  of  a  three  per  cent.  NaCl 
solution  passed  into  the  duodenum  in  ten  minutes : 

1.  Allow  500  c.c.  three  per  cent.  NaCl  solution  to  run  into  a 
clean  stomach  through  a  tube  and  remain  ten  minutes. 

2.  Draw  out  as  much  as  possible,  washing  out  the  last  with 
known  quantities  of  distilled  water. 

3.  Determine  the  amount  of  NaCl  as  stated  above,  and  add  the 
average  deficit  of  escape  into  the  duodenum. 

The  difference  between  the  original  amount  NaCl  and  the  amount 
regained  is  a  fairly  accurate  index  of  gastric  absorptive  power ;  or, 
by  our  method  of  duodenal  intubation,  occlude  the  pylorus  by 
blowing  up  a  balloon  in  front  of  or  beyond  it ;  pour  into  the  stomach 
through  a  tube  a  known  quantity,  say,  lOO  c.c,  of  a  one  per  cent, 
solution  of  maltose;  in  ten  to  twenty  minutes  aspirate  or  wash 
out  the  amount  of  maltose  left  as  above.  The  deficit  will  indicate  the 
amount  absorbed. 


CHAPTER  XI. 

METHODS    FOR    DETERMINING    THE     LOCATION,    SIZE, 
AND    CAPACITY    OF    THE    STOMACH. 

Percussion  and  Palpation. —  GastrodiapJiany  of  Einliorn. 

Distention  very  much  facilitates  percussion  and  palpation  of  the 
stomach. 

Percussion  of  the  stomach  gives  varying  results,  according  to 
its  contents  and  to  the  degree  of  its  distention.  The  fundus  is 
closely  applied  to  the  concavity  of  the  diaphragm,  and  five-sixths  of 
its  volume  is  to  the  left  of  its  median  line ;  only  one-sixth  to  the  right 
(observe  the  accompanying  illustrations  from  Eichhorst's  "  Klin. 
Untersuchungs-Methoden").  The  highest  point  is  the  fundus, 
which  reaches  the  lev^el  of  the  ninth  thoracic  vertebra.  The  lesser 
curvature  runs  along  the  left  of  the  spinal  column,  and  crosses  to 
the  right  at  the  level  of  the  first  lumbar  vetebra.  The  lesser  curva- 
ture is  entirely  covered  by  the  liver,  and  can  only  be  percussed  or 
palpated  when  it  is  located  lower  than  normal.  The  pylorus  is 
covered  by  the  right  lobe  of  the  liver,  about  three  to  four  cm.  from 
the  median  line ;  it  is  seven  cm.  lower  than  the  cardia.  The  pars 
pylorica  (antrum  pylori)  extends  further  to  the  right  than  the 
pylorus  itself.  The  greater  curvature  in  its  upper  part  is  largely 
covered  by  the  lung;  its  lower  and  anterior  part  is  in  apposition 
with  the  left  hypochondrium  and  epigastrium.  When  the  stomach 
is  full  the  greater  curvature  is  two  to  four  cm.  above  the  umbilicus. 
To  the  right  of  the  median  line  it  ascends  along  the  median  edge 
of  the  gall-bladder,  and  is  continued  into  the  pyloric  part.  (See 
illustration.) 

The  conviction  has  been  forced  upon  us  that  the  degree  to  which 
the  stomach  can  be  distended  is  a  very  limited  one.  This  state- 
ment is  made  after  many  distentions  with  the  intragastric  stomach- 
shaped  bag.  Most  stomachs  that  are  in  a  normal  state  will  refuse 
to  be  distended  more  than  lOO  c.c.  beyond  their  natural  capacity. 
Only  in  pathological  thinning  of  the  gastric  walls  and  in  atrophy 

97 


98 


LOCATION,    SIZE,   AND    CAPACITY    OF    THE    STOMACH. 


of  the  muscularis  is  an  over-distention  conceiv^able ;  even  then 
some  of  the  gases  will  escape  bythecardia  before  painful  distention 
will  ensue. 

For  these  reasons  distention  with  air  or  carbon  dioxid  is  an 
expedient  and  safe  way  of  determining  the  form  and  location  of 
the  stomach,  and  its  relation  to  any  tumors  that  may  be  present. 


Fig.  8. — Location  of  the  Stomach — Dorsal  View. 
I.  Left  kidney.     2.   Right  kidney.     3.  Spleen.     4.   Lungs.     5.   Descending  colon.     6.  Ascending  colon. 
7.  Complementary  space  occupied  by  expanding  lungs  in  inspiration.     The  stomach  occupies  the 
space  colored  in  red. 


Riegel  thinks  that  there  is  no  better  way  of  differentiating  gastric 
dilatation  from  gastroptosis  (falling)  than  by  this  process  of  dis- 
tention. 

This  method  is  carried  out  by  introducing  a  stomach-tube,  to 
the  upper  end  of  which  is  attached  a  double-bulb  pump  arrange- 
ment such  as  is  used  in  some  spray  apparati  (Runeberg, 
Deiitsch.  Arcliiv  f.  Kliii.  Med.,  Bd.  xxxiv).     Bouveret  ("Traite  des 


DISTENTION    WITH    AIR    OR    CO2. 


99 


Maladies  de  rEstomac,"  Paris,  1893)  recommends  that  the  air 
be  forced  into  the  stomach  by  blowing  with  the  mouth  through 
the  tube.  Riegel  and  Boas  are  very  fond  of  gastric  distention  by 
carbon  dioxid  gas.  A  teaspoonful  of  bicarbonate  of  sodium,  and 
about  the  same  amount,  or  perhaps  a  little  less,  of  tartaric  acid,  are 
dissolved,  each  in  a  separate  glass  containing  250  c.c.  of  water. 

First  the  solution  of  tartaric  acid  is  administered,  and  immedi- 
ately afterward   the    sodium   bicarbonate;    within  the   stomach  a 


Fig.  9  — Location  of  the  Stomach — Anterior  View. 
I.  The  stomach.    2.  Liver.    3.  Heart.    4.  Lungs.    5.  Complemental  pleural  spaces.    6.  Transverse  colon. 

brisk  evolution  of  COo  occurs,  at  once  distending  the  organ  so 
that  it  stands  out  prominently,  and  is  evident  as  a  sharply  defined, 
arched  elevation  ;  the  greater  curvature  becomes  very  apparent, 
not  so  the  lesser  one. 

The  stomach  under  distention  can  be  readily  palpated  or  per- 
cussed. If  tumors  were  made  out  before  the  distention,  it  is  im- 
portant to  determine  their  seat  after  the  distention.  It  is  possible 
in  many  cases  to  demonstrate  the  connection  or  non-connection  of 


100  LOCATION,    SIZE,  AND    CAPACITY    OF    THE    STOMACH. 

the  tumor  with  the  stomach  after  distention.  The  movability  of 
the  tumor  gives  us  some  information  as  regards  its  seat,  particu- 
larly if  it  be  carried  out  before  and  after  distention,  for  under  this 
method  the  organ  is  not  only  stretched  out  more,  but  undergoes  a 
certain  amount  of  turning  or  twisting  around  its  long  axis. 

Accordingly,  tumors  which,  when  the  stomach  was  empty,  were 
palpated  in  the  line  of  the  umbilicus  and  to  the  right,  and  for  that  rea- 


FiG.  lo. — Normal  Pekcussion  Limits  of    the  Adult  Stomach. — (Eichhorsi.) 
I.  Pronounced  liver  dullness.     2.  Lesser  liver  dullness.     3.  Smaller  heart  dullness.     4.   Larger  heart  dull- 
ness.    5.  Limits  of  stomach  percussion.     6.  Traube's  semilunar  space.     7.  Left  edge  of  short  ribs. 

son  it  might  be  doubted  whether  they  belonged  to  the  stomach,  after 
distention  may  move  upward  to  the  right,  and  toward  the  anterior 
arch  of  the  short  ribs.  One  may  see  and  feel  the  direct  transition 
of  the  tumor  mass  into  the  substance  of  the  stomach,  or  trace  its 
extent  over  the  small  curvature  toward  the  pylorus,  or  ascertain 
that  it  is  entirely  independent  of  the  stomach. 

Even  the  disappearance  or  the  becoming  less  distinct  of  a  tumor 
is  very  important,  if  it  occurs  after  distention.     This  is  observed  in 


DETERMINATION  OF  LOCATION  AND  SIZE  OF  THE  STOMACH.        lOI 

tumors  of  the  posterior  wall.  If  it  is  easily  movable,  very  close 
and  tight  adhesions  may  be  excluded ;  if  it  is  absolutely  immova- 
ble, it  is  abnormally  attached  or  fixed.  It  is  evident  that  disten- 
tion of  the  stomach  with  air  or  gas  not  only  enables  one  to  get 
a  better  percussion  area,  but  it  serves  another  purpose  :  that  of 
facilitating  the  palpation  of  tumors.  In  his  new  book  on  "  Dis- 
eases of  the  Stomach,"  Riegel  gives,  in  addition  to  the  above,  ten 
other  methods  for  determining 

Location,  Size,  and  Capacity. — Most  of  which  being  more  or 
less  fallacious,  we  must  refer  those  specially  interested  in  this  matter 
to  Riegel's  book,  pages  41-56,  In  our  opinion,  all  of  these  methods 
will,  before  many  years,  have  only  a  historical  value.  There  is 
one  method  for  accomplishing  the  above  objects,  however,  which 
we  can  recommend  from  a  very  large  experience,  and  which 
is  used  exclusively  at  our  clinic,  and  with  the  accuracy  of  which 
we  have  had  many  opportunities  to  be  convinced.  It  is  described 
and  pictured  on  page  32  of  this  work. 

With  our  stomach-shaped  intragastric  rubber  bag  (see  plate  iv) 
and  the  pressure  bottles  A  and  B,  the  location  and  capacity  can 
be  determined  with  great  ease.  The  rubber  bag  used  for  this  pur- 
pose has  no  sheath  or  guide  for  the  duodenal  tube.  The  stomach 
is  distended  by  blowing  up  the  bag  within  it;  the  amount  of  air 
necessary  thereto  is  measured  afterward  by  allowing  it  to  escape 
into  a  spirometer  ;  a  less  accurate,  though  a  quite  practical  method, 
is  to  catch  the  escaping  air  in  a  glass  cylinder  filled  with  water  and 
inverted  over  a  basin. 

It  might  be  claimed  that  our  method  is  a  combination  of  von 
Kelling's,  Schreiber's,  and  Jaworski's  methods,  and  it  does  indeed 
partake  of  part  of  the  devices  of  all  these  (see  Riegel,  pp.  51,  52, 
and  54).  Schreiber  used  a  small,  round — not  a  stomach-shaped 
— distensible  balloon,  but  no  pressure  bottles  nor  spirometer. 
Jaworski  used  two  pressure  bottles,  but  no  balloon  or  intragastric 
bag,  and  no  spirometer,  while  von  Kelling  used  simply  the  spir- 
ometer to  measure  the  air,  which  he  forced  into  the  stomach  with 
a  double  bulb,  as  is  used  on  sprays. 

Our  method  of  arriving  at  the  capacity  of  the  stomach  is  really, 
then,  not  entirely  original,  as  it  combines  the  best  of  three  older 
methods,  but  it  is  most  convenient  and  reliable ;  the  bag,  as  has 
been  shown,  can  at  the  same  time  be  used  for  determining  the 
nature  of   the   motor   function.     It   can  be   asserted,   from  obser- 


I02  LOCATION,    SIZE,    AND    CAPACITV    OF    THE    STOMACH. 

vations  on  a  large  number  of  patients,  that  there  is  no  other 
single  method  which  is  so  useful,  and  can  combine  instruction 
concerning  size,  location,  and  capacity  of  the  stomach  with  that 
concerning  its  motor  function. 

The  method  is  as  easy  in  its  application  as  any  which  Riegel 
describes.  The  capacity  can,  for  practical  purposes,  be  read  off  on 
bottle  B,  from  the  amount  of  air  that  has  been  displaced  into  the 
intragastric  bag.  The  expense  of  the  bag  is  one  dollar,  and  a 
good  idea  of  the  motor  function  can  be  gotten  from  a  water  man- 
ometer in  connection  with  it  after  distention  ;  with  one  hand  on  the 
epigastric  region,  the  respiratory  movements  can  be  felt,  and  thus 
distinguished  from  the  active  movements  as  expressed  by  the  rise 
and  fall  of  the  water  column  in  the  manometer.  It  may  thus  be 
used  without  the  kymograph.* 

Gastrodiaphany  of  Einhorn. — In  1889  Dr.  Max  Einhorn  suc- 
ceeded in  transilluminating  the  human  stomach  in  the  dark  by 
means  of  a  small  Edison  lamp  attached  to  a  soft  rubber  tube;  from 
the  lamp,  through  this  tube,  insulated  conducting  wires  run  to  a 
storage  battery.  (See  illustration  p.  103.)  At  some  distance  from 
the  rubber  tube  is  a  current-interrupter.  By  this  apparatus  the  in- 
ventor claims  to  be  able  to  ascertain  the  exact  position  and  size  of 
the  stomach,  and  to  recognize  tumors  and  thickenings  of  the  front 
wall  by  their  lack  of  translucency. 

In  1867  Milliot  had  succeeded  in  transilluminating  the  stomachs 
of  animals  by  platinum  wires  contained  in  glass  tubes  and  con- 
nected with  a  Middeldorph's  apparatus. 

Fleischer,  in  his  text-book  ("  Path.  u.  Therap.  der  Magen-  u. 
Darmkrankh.,"  p.  789),  claims  to  have  succeeded  in  transillumin- 
ating the  human  stomach,  together  with  Hiifler,  before  Einhorn. 
If  this  is  really  so,  Fleischer  did  not  publish  his  investigations,  as 
far  as  we  know,  and  certainly  is  not  entitled  to  call  the  method 
after  himself — the  gastrodiaphany  of  Fleischer  and  Hiifler. 

To  Einhorn  is  due  the  credit  of  developing  the  method  as  an 


*  In  the  shops  of  Baltimore  small  toj'  balloons  are  sold ;  they  are  made  of  very  thin 
but  quite  tough  rubber,  which  my  assistants  have  frequently  used  for  intragastric  disten- 
tion. These  balloons  accompany  a  game  called  "  pillow  dex,"  and  are  sold  six  for  25 
cents.  For  studying  the  motor  function  they  answer  as  well  as  the  more  expensive 
stomach-shaped  bags,  as  I  have  assured  myself  that  on  distention  they  fill  every  inch  of 
space  in  a  dog's  stomach.  For  determining  the  capacity,  however,  the  stomach-shaped 
bag  is  more  accurate. 


ELECTRIC    TRANSILLUMINATION    OF    THE   STOMACH. 


103 


aid  to  diagnosis.  The  patient,  in  a  fasting  condition,  drinks  a  liter 
of  water;  the  apparatus  is  passed  into  the  stomach  just  as  the 
lavage  tube  is  passed,  and  connected  with  the  storage  battery. 
The  stomach  transmits  the  electric  light  through  the  abdominal 
walls,  becoming  visible  as  a  red  zone  at  the  place  which  corre- 
sponds to  its  location. 

In  case  the  anterior  gastric  wall  is  occupied  by  a  tumor  the  light 
will  not  be  transmitted  at  that  spot,  but  all  around  it  the  rays  will 
penetrate,  thus  evincing  a  dark,  shaded  area  in  a  luminous  zone. 

We  are  in  the  habit  of  marking  the  ribs,  particularly  the  um- 
bilicus, xiphoid  cartilage,  and  symphysis  pubes,  with  phosphorus, 
so  that  they  can  be  seen  in  the  dark  and  serve  as  landmarks  to  the 


Fig.  II. — The  Electrodiaphane. 


exact  abdominal  area  in  which  the  light  permeates.  Dr.  Howard 
A.  Kelly  prompted  us  to  attempt  transillumination  of  the  colon  by 
this  method,  and  we  succeeded  admirably. 

We  have  been  able  to  illuminate,  in  successive  portions,  the 
entire  colon  in  this  manner,  and  demonstrated  prolapse  of  the 
colon  thereby;  even  into  the  duodenum  and  ileum  the  diaphane 
has  been  introduced  by  us,  and  we  claim  these  advances  of  the 
method  as  original  to  our  clinic. 

Notwithstanding  the  conservatism  of  Riegel  and  Fleiner 
("  Lehrbuch  d.  Krankh.  d.  Verdauungs-Organe,"  p.  223),  and  the 
objections  of  Boas,  and  Debove,  and  Remond,  we  consider  the 
method  valuable  ;  it  certainly  is  convenient  for  the  rapid  diagnosis 
and  the  differentiation  between  gastrectasia  and  gastroptosis. 


104  LOCATION,    SIZE,    AND    CAPACITY    OF    THE    STOMACH. 

It  should  be  added,  however,  that  we  use  a  much  stronger  light 
(namely,  eight  to  ten  volts)  than  Einhorn,  and  have  one-half  of  the 
lamp  coated  by  a  reflecting  mirror  of  mercury,  which  can,  of 
course,  be  controlled  by  turning  the  tube  outside  of  the  mouth. 
At  a  demonstration  which  we  were  requested  to  give  before  the 
Clinical  Society  of  Maryland,  the  apex  impulse  of  the  heart  was 
visible  in  the  dark  after  transillumination. 


CHAPTER  XII. 

THE  STOMACH-TUBE  AND  TECHNICS  OF  ITS 
INTRODUCTION. 

Examinatioji  of  StomacJi  Contents. —  Test-vieals :   Their  Effect  upon 
the  Amonnt  of  Acid  Secreted. 

We  never  use  any  other  kind  but  a  soft  elastic  stomach-tube, 
and  before  introducing  it  for  the  first  time  in  any  patient,  we 
always  instruct  him  or  her  carefully  about  the  object  and  utility  of 
the  procedure  and  its  harmlessness.  Whenever  we  can  do  so  we 
give  very  timid  patients  an  opportunity  of  observing  with  what 
ease  more  experienced  patients  introduce  the  tube  on  themselves. 
This  has  a  most  comforting  effect.  Weak  and  old  persons  should 
always  be  treated  on  the  bed,  several  thick  towels  being  placed  on 
the  patient's  chest  and  beneath  the  chin ;  if  the  case  is  to  be  ex- 
amined in  an  erect  position,  linen  gowns  are  drawn  over  the  breast 
and  lap,  or  an  additional  rubber  sheet  to  protect  the  clothing.  Dr. 
Fenton  B.  Turck,  of  Chicago,  has  devised  a  useful  rubber  pockety 
which  is  suspended  under  the  chin  during  lavage,  and  protects  the 
garments  of  the  patients  from  the  mouth  discharges.  If  the  throat 
and  fauces  are  very  tender  (often  found  in  excessive  smokers),  it  is 
advisable  to  precede  the  introduction  of  the  tube  by  spraying  the 
throat  with  a  three  per  cent,  solution  of  cocain  hydrochlorate  or 
the  following  anodyne  spray: 

U.      Three  per  cent,  solution  of  Cocain  hydrochlorate  in  Benzoinol,  .  f^j 

One  per  cent,  solution  of  Menthol  in  liquid  Vaselin  oil, ^o^^- 

Use  in  atomizer  for  spraying  the  throat.  IMix. 

It  is  not  necessary  to  lubricate  the  stomach- tube  with  any  oil  or 
vaselin, — there  is  generally  mucus  enough  in  the  esophagus  to 
facilitate  the  passage. 

In  the  New  York  Medical  Jotirnal  for  December  28,  1895,  volume  lxii, 
No.  26,  page  822,  a  new  double-current  stomach-tube  has  been  described  by 
the  author,  through  which  the  inflow  and  outflow  goes  on  uninterruptedly  at 
the  same  time.  This  tube  is  recommended  only  as  a  time-saver  for  the  spe- 
cialist in  practice  :  the  simple  tube  will  fulfil  every  requirement,  even  though 
lavage  of  progressed  gastrectasia  may  require  much  more  time. 

s  10; 


io6 


STOMACH-TUBE    AND    TECHNICS    OF    ITS    INTRODUCTION. 


From  20  measurements  of  living  female  patients,  the  author  has  found 
that  the  average  distance  from  the  incisor  teeth  to  the  deepest  portion  of  the 
stomach  is  55  cm.,  and  in  36  measurements  of  healthy  males  the  same  distance 
was  found  to  be  60  cm.  In  cadavers  this  is  in  both  sexes,  according  to  the 
author's  experience,  shortened  by  postmortem  rigor,  it  having  been  found  to 
be  52.5  cm.  on  the  average  for  females  in  12  different  subjects.  In  12  male 
cadavers,  the  average  distance  from  the  incisor  teeth  to  the  deepest  part  of  the 
stomach  was  54  cm. 

In  ten  cases  of  dilatation  of  the  stomach,  the  average  distance  from  the  in- 
cisor teeth  to  the  deepest  portion  of  the  stomach,  as  measured  by  as  rigid  a 
sound  as  could  safely  be  introduced,  was  69  cm.  In  ordering  the  new  double- 
current  tube,  however,  from  Tiemann  &  Co.,  the  manufacturers  were  directed  to 
make  the  proportion  which  is  introduced  into  the  body  70  to  72  cm.  long, 
which  length,  on  the  basis  of  the  foregoing  measurements,  was  considered 


Fig.  12. — Hemmeter's  Double-current  Stomach  Lavage  Tube. 


sufficient  for  all  requirements.  The  amount  flowing  down  through  the  inflow 
tube  will  vary  with  the  height  of  the  pressure  bottle,  but  should  never  exceed 
more  than  one  liter  in  two  minutes  ;  in  the  same  tube  the  outflow  channel 
should  be  able  at  the  same  time  to  discharge  by  simple  siphonage  two  liters. 

The  inflow  and  outflow  tube  should  be  tested  as  regards  their  caliber,  the 
former  by  pressure,  the  latter  by  siphonage,  before  they  are  used  on  patients. 

When  the  outflow  tube  is  tested  as  regards  the  amount  of  water  it  will  dis- 
charge in  a  given  time,  the  tube  should  be  arranged  as  in  figure  13,  so  that  the 
water  must  rise  70  cm.,  the  distance  from  the  deepest  portion  of  the  stomach 
to  the  incisor  teeth,  before  it  can  descend  into  the  measuring  graduate. 

The  procedure  of  lavage  must  be  attentively  watched  in  cases  where  much 
solid  debris  is  expected,  and  if  the  outflow  becomes  choked  with  solid  matter 
the  inflow  must  be  cut  off  at  once  until  the  outward  passage  is  made  clear. 

A  piece  of  glass  tubing  two  inches  long,  firmly  tied  to  the  outflow  tube,  is 
useful,  in  that  it  permits  the  operator  to  observe  the  material  which  is  running 


THE  RECURRENT  STOMACH-TUBE. 


107 


out.  The  single  stomach-tube  has  been  swallowed  entirely  and  disappeared 
into  the  stomach.  At  least  two  such  accidents  are  on  record,  one  by  Leube 
(33),  the  other  by  Jackson  (35);  they  are  both  quoted  by  William  H.  Welch, 
in  his  article  on  "  Dilatation  of  the  Stomach  "  in  Pepper's  "  American  Sys- 
tem of  Medicine,"  volume  11. 

With  a  double,  or  current,  tube  this  accident  is  impossible,  as  the  instrument 
is  tied  to  the  supply  reservoir.  Aspiration  of  the  mucosa,  and  tearing  of  pieces 
of  healthy  membrane  by  suction,  which  has  occurred  in  Leube's  experience 
(2),  is  also  a  matter  of  impossibility  with  the  recurrent  tube.  Physicians  who 
have  used  gastric  lavage  with  a  simple  funnel,  know  how  difficult  it  is  to  keep 


Fig.  13. — Illustrating   the    Principle    of 

SiPHONAGE. 


Fig.  14. — Bulb  Used  for  the  Aspiration 
OF  Test-meals  with  Patients  having 
Very  Relaxed  Abdominal  Walls. 


air  from  being  sucked  into  the  stomach  ;  a  deep  depression  of  air  forms  in  the 
center  and  is  occasionally  aspirated  into  the  stomach  ;  all  of  this  is  avoided  in 
the  recurrent  tube.  The  author,  on  visiting  Professor  F.  Penzoldt,  in  Erlangen, 
in  July,  1895,  was  surprised  to  find  this  pioneer  of  digestive  pathology  still  ad- 
vocating the  use  of  a  guide  in  the  shape  of  a  flexible  stick  or  whalebone,  which, 
during  introduction,  is  inserted  into  the  gastric  tube  to  facilitate  its  entering 
the  esophagus  after  it  curves  over  the  base  of  the  tongue. 

In  his  most  recent  contribution  to  the  subject,  Penzoldt  [loc.  cit.,  27)  gives 
minute  details  as  regards  the  method  of  application  of  the  Leitungsstab  or  Alati- 


I08  STOMACH-TUBE    AND    TECHNICS    OF    ITS    INTRODUCTION. 

driti  within  the  tube,  and  says  that  it  should  be  oiled  to  facilitate  its  removal 
when  the  tube  has  reached  the  middle  of  the  esophagus.  He  also  suggests 
catching  the  tip  of  the  lavage  tube  between  the  index  and  middle  finger  of  the 
left  hand,  which  are  inserted  into  the  patient's  mouth,  and  bending  the  tip 
down  over  the  base  of  the  tongue  until  it  enters  the  esophagus.  This  is  the 
method  advocated  by  his  teacher.  Professor  Leube  (^loc.  cit.,  2),  and  also  by 
Rosenheim  (36). 

In  the  writer's  experience  the  intratubal  whalebone  guide  and  the  insertion 
of  the  fingers  into  the  patient's  month  are  superfluous.  The  tube  can  always 
be  introduced  without  a  guide,  and  without  touching  the  patient.  The  main 
point  is,  that  the  point  of  the  tube,  when  it  has  reached  the  wall  of  the  pharynx, 
shall  be  deflected  downward.  This  will  occur  without  exception,  and  in  a 
very  natural,  easy,  manner,  if  the  patient  is  directed  to  swallow  at  this  moment. 
In  the  moment  of  this  act  of  deglutition  the  point  of  the  tube  is  bent  downward 
into  the  esophagus. 

Beginners  in  using  the  tube  need  have  no  fear  that  it  will  enter  the  trachea. 
To  make  it  enter  the  trachea  is,  in  the  writer's  experience,  a  difficult  undertak- 
ing, and  requires  special  training  and  dexterity.  He  was  present  on  an  occa- 
sion when  a  class  of  ten  students  were  taking  a  private  course  in  diseases  of 
the  throat,  during  which  lesson  they  were  trying  to  mop  the  larynx.  What 
they  really  did  was  to  mop  out  the  superior  portion  of  the  esophagus.  Direct 
the  patient  to  keep  taking  deep  inspirations,  and  as  soon  as  the  tip  or  point  of 
the  tube  is  felt  touching  the  pharyngeal  wall  tell  him  to  swallow,  and  almost 
immediately  the  tube  follows  into  the  esophagus  and  can  be  pushed  into  the 
stomach  without  further  resistance.  The  double  or  recurrent  tube  is  still  in  its 
experimental  stage  and  can  not  be  recommended  as  practical. 

It  is  not  necessary  for  the  patient  to  open  his  teeth  any  wider 
than  just  to  admit  the  sound  ;  at  the  same  time,  caution  him  not  to 
bite  on  it,  but  to  breathe  naturally.  No  patient  should  be  sub- 
jected to  gastric  lavage  without  a  previous  examination  of  the 
thorax.  Penzoldt  tells  of  a  case  in  which  the  stomach  should  have 
been  washed  out  in  the  morning,  but  on  account  of  lack  of  time  this 
was  postponed  until  the  same  evening.  On  the  same  afternoon  the 
patient  died  of  rupture  of  an  aortic  aneurism  into  the  esophagus. 
Lavage  and  introduction  of  the  tube  is  contra-indicated — 

I.  In  all  constitutional  and  local  diseases  which  could  be  aggra- 
vated or  life  endangered  by  the  irritation  and  exertion  of  lavage. 
Among  these  could  be  mentioned : 

1.  Pregnancy  (though  this  is  not  a  disease). 

2.  Heart  disease  in  a  state  of  defective  compensation — heart 
neuroses,  angina  pectoris,  myocarditis,  and  fatty  heart  in  an 
advanced  stage. 

3.  Aneurism  of  the  large  arteries. 

4.  Recent  hemorrhages   of  all  kinds,  including  apoplexies,  pul- 


CONTRA-INDICATIONS    TO    LAVAGE.  IO9 

monary,  renal,  vesical,  gastric,  rectal  hemorrhages,  and  hemorrhagic 
infarctions. 

5.  Advanced  pulmonary  tuberculosis. 

6.  Advanced  pulmonary  emphysema,  with  bronchitis. 

7.  Apoplexy  and  cerebral  hyperemia. 

8.  Advanced  cachexia. 

9.  Presence  of  continued  or  remittent  fever. 

II.  The  stomach  and  intestinal  diseases  which  are  contra-indica- 
tions  of  the  use  of  tube  are  : 

1.  Ulcer,  with  recent  hematemesis  and  dark  stools. 

2.  Palpable  carcinoma  of  the  pylorus,  with  vomiting  of  coffee- 
ground  material  and  the  classical  symptoms  of  cancer. 

3.  Many  gastric  neuroses  in  which  the  character  of  the  malady 
is  clear  without  lavage. 

4.  Stomach  or  intestinal  troubles,  with  acute  fever. 

5.  Gastric -mucosa  easily  started  to  bleeding. 

6.  Secondary  gastric  affections  whose  dependence  upon  a  dis- 
tinct and  more  important  primary  disease  is  evident. 

These  are  not  invariable  rules,  however;  cases  may  occur 
under  some  of  these  exceptions,  that  at  times  peremptorily  re- 
quire lavage  on  account  of  depressing  self-intoxication  from  the 
stomach  or  advanced  gastric  fermentation.  Thus,  according  to 
Boas,  it  has  been  employed  with  success  in  pregnancy,  and  the 
author  has  once  washed  out  the  stomach  in  a -case  of  typhoid  fever 
with  favorable  result,  and  also  performed  lavage  in  a  case  of  aortic 
regurgitation,  with  Bright's  disease  and  gastrectasia,  where  much 
relief  was  experienced  from  the  procedure.  Professor  Moritz,  of 
Munich,  has  frequently  passed  the  stomach-tube  in  pregnant 
women  to  ascertain  the  intragastric  pressure  (25). 

In  a  normal  position  of  the  abdominal  viscera  the  location  of  the 
cardia  corresponds  to  the  spinous  process  of  the  ninth  thoracic  ver- 
tebra. By  counting  ofTthis  process  on  the  back  of  the  patient  and 
placing  the  upper  eye  of  the  sound  against  it,  one  can  measure  the 
length  of  tube  necessary  to  reach  the  stomach  by  applying  it  from 
this  point  along  the  back,  passing  alongside  of  the  ear  to  the  front 
incisor  teeth.  At  this  point,  which  reaches  the  incisors,  it  is  of 
assistance  to  make  a  mark  on  the  rubber  with  a  nitrate  of  silver 
point ;  this  will  avoid  pushing  the  tube  out  or  in  to  discover 
whether  it  has  reached  the  stomach  after  being  introduced. 

In  dilations  and  falling  of  the  organ,  the  length  of  tube  required 


I  lO 


STOMACH-TUBE    AND    TECHNICS    OF    ITS    INTRODUCTION. 


can  onl\'  be  learned  after  a  previous  lavage.  When  the  sound  is 
used  to  draw  out  a  test-meal,  direct  the  patient  to  press  in  his  ab- 
dominal muscles  as  if  in  the  act  of  having  a  stool.  Frequently  the 
accompan\-ing  nausea  will  bring  this  about  involuntarily.  If  no 
contents  arise,  push  the  tube  gently  further  in  or  pull  it  slowly  out, 
and  try  both  ways.  If  the  abdominal  walls  are  flabby,  external 
manual  compression  will  sometimes  produce  the  desired  result.  If 
all  these  manipulations  are  of  no  avail,  the  stomach  is  either  empty 
or  the  tube  is  plugged  up  with  food-particles  too  large  to  pass. 

To  find  out  which  is  the  case,  allow  300  c.c.  of  pure  water  to  run 
in  and  then  lower  the  funnel  and  siphon  out ;  if  nothing  but  com- 
paratively clear  water  returns,  the  test-meal  has  passed  into  the 
duodenum.     One  should  be  very  cautious  in  moving  the  tube  out 

and  in  when  no  stomach  con- 
tents appear  in  the  funnel,  as 
it  is  possible  that  the  eyes  of 
the  tube  may  have  sucked  in 
the  gastric  mucosa  itself,  and 
by  moving  too  suddenly  a 
piece  may  be  torn  away.  If 
there  is  the  least  resistance, 
avoid  moving;  rather  pour  in 
a  small  amount  of  water, 
which  will  push  away  the 
adherent  mucosa  or  the  food- 
particle,  and  the  next  attempt 
will  bring  up  the  test-meal. 
If  the  stomach  is  already  empty,  the  test-meal  must  be  given 
again  at  another  time.  We  never  recommend  any  apparatus  for 
aspiration,  not  even  the  rubber  bulb;  with  patience  the  simple  ex- 
pression method  will  suffice.  For  small  samples  of  test-meals  the 
Einhorn  stomach  bucket  (Einhorn,  "Diseases  of  the  Stomach," 
p.  63)  is  an  available  instrument.  We  do  not  recommend  the  recur- 
rent stomach-tube,  except  as  a  time-saver,  and  are  aware  that  its 
usefulness  is  very  limited.  Before  using  the  tube,  all  artificial 
teeth  should  be  removed. 

In  very  rare  cases  of  intense  food  and  mucus  putrefaction,  and  in 
extensive  gastrectasis,  a  recurrent  tube  may  be  used  with  success. 
To  give  an  idea  of  the  time  it  takes  to  cleanse  some  stomachs,  we 
quote  Dr.  Herman  Strauss,  assistant  to    Prof.  Riegel,  who  claims 


Fig.  15. — EwALD  Stomach-tuee. 


VARIETIES    OF    TEST-MEALS.  Ill 

to  have  washed  out  rice  particles  after  40  liters  of  water  had  been 
allowed  to  flow  in  and  out.  After  washing  a  dilated  stomach  for 
one  hour  personally,  we  found  bread  and  stringy  mucus  in  the  last 
washing.  Before  introducing  a  stomach-tube,  assure  yourself  that 
its  lumen  is  not  obliterated,  and  warm  it  in  a  pitcher  of  warm  water. 

Test-meals. — The  test-meal  most  frequently  employed  is  that 
of  Ewald  and  Boas,  consisting  of  a  roll  or  a  piece  of  wheat  bread 
and  500  c.c.  of  water  or  tea,  without  milk  or  sugar.  The  time  for 
examination  is  one  hour  after  the  meal. 

Leube  and  Riegel  advocate  a  test-dinner  of  400  c.c.  soup,  a  por- 
tion of  beefsteak  or  roast  beef,  potatoes,  and  a  roll.  The  time  for 
examination  is  three  to  four  hours  after  this  meal. 

Jaworski  and  Gluczinski  employ  the  white  of  a  hard-boiled  egg 
and  100  c.c.  water. 

Klemperer  recommended  }i  of  a  liter  of  milk  and  70  gm.  of 
wheat  bread,  and  examined  two  hours  later. 

Germain  See  used  60  to  80  gm.  scraped  meat  and  150  gm.  white 
bread.     Examination  two  hours  later. 


Fig.  16. — The  Esophageal  Tubal  Probe. 

The  Ewald  and  Boas  test-breakfast  seems  the  most  convenient, 
and  in  cases  of  enfeebled  digestion,  where  much  food  is  retained 
from  previous  meals,  the  least  confusing. 

Kleiner's  test-meal  consists  of  soup,  roast  beef,  and  potato  puree, 
he  examines  three  to  four  hours  after  the  meal. 

At  the  Maryland  General  Hospital  we  generally  use  a  double 
test-meal  consisting  of: 

8  A.M. — I   small  piece  of  beef,  scraped  and  broiled  ^=  80  gm.  ;    i   soft-boiled 
egg ;  30  gm.  boiled  rice  ;   i  glass  of  milk=25o  c.c,  and  a  piece  of  bread. 

Four  hours  later  an  Ewald  test-meal  is  given,  and  one  hour  after 
this  the  stomach  contents  are  drawn.  In  giving  a  test-meal,  always 
insist  on  good  chewing,  and  urge  that  all  food-substances  be  very 
finely  cut  up  so  that  they  can  not  plug  up  the  tube,  even  if  not 
digested. 

The  double  test-meal,  about  which  the  late  Dr.  Henry  Salzer,  of 
Baltimore,  was  quite  enthusiastic,  really  offers  some  advantages 
over  others.    In  the  first  place,  it  permits  of  as  easy  a  study  of  the 


112  STOMACH-TUBE    AND    TECHNICS    OF    ITS    INTRODUCTION. 

various  stages  of  the  digestion  and  of  the  motihty  and  degree  of 
retention  as  Riegel's  test-dinner ;  but  the  main  advantage  of  the 
double  test-meal — a  full  meal  at  8  or  9  a.  m.  and  an  Ewald  test- 
meal  at  12  M.  or  I  P.M.,  examination  at  i  or  2  p.m. — is,  that  after 
drawing  it,  we  may,  in  a  large  number  of  instances,  recognize  con- 
ditions of  gastric  motility  and  secretion  before  we  analyze  the 
contents.  For  instance,  disappearance  of  the  entire  breakfast-meal 
points  to  a  normal  digestion. 

Absence  of  all  proteids, — beef  and  egg, — and  presence  of  consid- 
erable carbohydrates, — rice  and  bread, — points  to  hyperchlorhy- 
dria  ;  and,  again,  absence  of  all  carbohydrates  and  presence  of  some 
of  the  beef  and  egg  points  to  hypochlorhydria,  subacidity,  or  ana- 
cidity.  Presence  of  the  entire  meal,  with  perhaps  milk  uncurdled, 
means  impaired  motility,  with  atrophy  of  gastric  mucosa,  absence  of 
acid,  enzymes,  and  pro-enzymes.  If  the  entire  breakfast  has  disap- 
peared, the  status  of  the  gastric  secretions  may  be  ascertained 
from  the  Ewald  test-meal  which  is  still  present. 

The  objection  which  has  been  made,  that  the  double  meal  is 
uncleanly  to  handle  during  analysis,  has  also  been  urged  against 
Riegel's.  Whether  the  morsels  of  an  Ewald  test-meal  are  more 
appetizing  and  esthetic  to  handle  than  remnants  of  our  double 
test-meal,  is  a  matter  concerning  which  it  does  not  pay  to  quarrel. 
It  is  a  very  important  matter  to  state  what  test-meal  is  used  in 
giving  out  the  various  acidities  obtained,  because  some  test-meals 
are  greater  stimulants  to  the  gastric  mucosa  than  others. 

The  Ewald  test-breakfast  really  makes  very  slight  demands  upon 
the  working  capacity  of  the  stomach. 

The  total  acidity  one  hour  after  an  Ewald  test-breakfast  is  nor- 
mally about  60 ;  the  lowest  total  acidity  observed  by  us  one  hour 
after  a  test-breakfast  of  this  kind  in  a  healthy  individual  was  22. 
Fleiner,  who  uses  a  test-meal  of  soup,  roast  beef,  and  potato  puree, 
asserts  that  three  to  three  and  a  half  hours  after  this  test-meal 
the  total  acidity  is  normally  70  to  lOO  (Prof  Wilhelm  Fleiner, 
"  Lehrbuch  d.  Krankheiten  d.  Verdauungs  Organe,"  p.  186).  Dr. 
Julius  Friedenwald  has  found  that  the  gastric  secretion  of  HCl 
appears  sooner,  and  reaches  a  higher  degree  after  our  double  test- 
meal  than  after  an  Ewald  meal. 

An  amount  of  HCl  equal  to  o.i  to  0.2  per  cent,  may  be  regarded 
as  normal ;  everything  below  that  means  subacidity,  above  this, 
hyperacidity.     The  total  acidity  can  not  correctly  be  regarded  as  an 


ACIDITIES    AFTER    VARIOUS    TEST-MEALS. 


113 


unfailing  indication  of  the  amount  of  HCl  present ;  the  latter  should 
always  be  determined  separately  in  addition  to  the  total  acidity. 

Apparently  there  are  climatic,  barometical,  and  geographical  fac- 
tors which  influence  the  total  acidity.  In  170  cases  at  Riegel's 
clinic,  Strauss  found  the  total  acidity  after  a  test-breakfast  equal  to 


Fig.  17. — Stomach-pump  used  only  for  Rapid  Evacuation  of  Poisons. 


68;  in  92  cases  at  Berlin  after  a  test-breakfast  the  average  total 
acidity  was  estimated  at  47 ;  the  average  amount  of  free  hydro- 
chloric acid  at  Riegel's  clinic  was  found  to  be  37.  Normal  values, 
one  hour  after  a  test-breakfast  of  a  roll  and  water,  are,  for  average 
total  acidity,  40  to  60 ;  for  free  HCl,  20  to  30,  for  Baltimore. 


114 


STOMACH-TUBE    AND    TECHNICS    OF    ITS    INTRODUCTION. 


After  the  complex  meal  of  Salzer,  /.  c,  five  hours  after,  50  to  60 
grs.  beef,  500  c.c.  milk,  70  grs.  rice,  and  one  egg,  the  total  acidity 
on  the  average  was  found  to  be  95°  and  the  free  HCl46°,  for  Balti- 
more. It  should  be  emphasized  that  these  figures  represent  only 
relative  values.  One  often  finds  every  symptom  of  hyperacidity 
with  relief  following  the  use  of  alkalies,  when  the  total  acidity  was 
found  to  be  only  56°  (one  hour  after  an  Ewald  breakfast),  the  free 
HCl  only  24.^.  On  the  other  hand,  cases  have  presented  them- 
selves showing,  under  the  same  conditions,  a  total  acidity  of  80° 
and  free  HCl  =  50°,  still  no  symptoms  of  hyperacidity.  All  this 
\  goes  to  show  that  some  stomachs  may  do  their  work  normally  very 
well  on  relatively  low  amounts  of  free  HCl,  and,  of  course,  suffer 
from  hyperacidity  from  comparatively  slight  increase  of  free  HCl, 
which  would  not  affect  a  stomach  used  to  higher  amounts  of  acid. 


Fig.  18. — Modified  Ewald  Tube,  with  numerous  smaller  and  larger  Lower  Openings. 

Most  modern  observers  that  can  speak  with  authority  on  the 
subject,  agree  that  the  total  acidity  should  not  be  employed  to  ex- 
press hyperacidity,  but  only  the  amount  of  free  HCl,  as  this  is  the 
only  acid  which,  when  increased,  gives  rise  to  the  complex  of 
symptoms  technically  recognized  as  hyperacidity. 

Before  closing  this  chapter  it  might  be  added,  that  where  it  is 
impossible  to  use  the  tube  on  account  of  prejudice  of  the  patient,  to 
obtain  a  test-meal,  emesis  may  be  resorted  to.  The  stomach  con- 
tents obtained  after  a  test-meal,  as  a  rule,  filter  slowly,  and  if  much 
mucus  is  present,  not  at  all.  The  filtration  can  be  accelerated  by 
rubbing  the  material  first  through  a  small  coarsely-grained  sieve 
(strainer),  then  through  a  finely-grained  strainer,  and  then  filtered 
through  Swedish  filter  paper. 


BIBLIOGRAPHY.  II5 

LITERATURE 

OX   THE    HISTORY   AND    TECHNICS    OF    THE   STOMACH-TUBE. 

1.  Kussmaul,  "  Behandl.  d.  Magenenveit.  durch  eine  neue  ^lethode  mit  der 
Magenpumpe,"  Deiiisch.  Arch.f.  klin.  Med.,  w,  455. 

2.  Leube,  "  Die  Magensonde,"  Erlangen,  1879. 

3.  Eu'ald,  C.  A.,  "  Klinik  d.  Verdauungskrankheiten,"  Berlin,  i890-'93. 

4.  Bush,  F.,  Lo7idon  Medical  and  Physic.  Journal,  1S22. 

5.  Arnott,  quoted  by  Alderson,  on  the  "Dangers  attending  the  use  of  the 
Stomach  Pump,"  Lancet,  January  4,  1879. 

6.  Canstatt,  "Text-Book,"  Erlangen,  1846,  vol.  iii,  p.  382. 

7.  "  Hieronym.  Fabric,  ab  Aquapendente,"  Chirurg.  Schrift.,  ed.  Joh. 
Scultetus,  Niirnberg,  17 16,  11.  Theil,  Cap.  39,  S.  92. 

8.  Nicander,  "Alex.  Phar.,"  Edit.  Paris,  1857,  p.  155. 

9.  "  Collecta  medicinalia  of  Oribasius,"  vol.  yiii,  cap.  yi. 

10.  Avicenna,  "Liber  Canonis,"  etc.,  1544,  Ausg.  Venice,  liber  i,  fen.  iy, 
chap.  20,  p.  83. 

11.  Hieronymus  ^lercurialis,  "  De  Morbis  venenosis  et  venenis,"  Venetiis, 
1583,  liber  i,  cap.  22. 

12.  Joh.  Arculani  A'eronensis,  "  Practica,"  etc.,  Venice,  1557,  p.  82. 

13.  W.  H.  Ryff,  "Gross.  Chirurgie,"  Frankfurt  a.  ^L,  1559,  Theil  I,  p.  37. 

14.  Scultetus,  Joh.,  "  Wundartzneyisches  Zeughaus,"  Frankfurt,  Llm,  1679, 
S.  108. 

15.  Gulielmus  Fabricus,  Hildanus,  "Observation  et  curat.  Chirurg.  Cen- 
turis  1641,"  cent,  i,  observ.  36. 

16.  Dapper,  "Die  unbekannte  neue  Welt,"  etc.,  Amsterdam,  1573, 
S.  566. 

17.  Rumsaeus,  "  Organum  Salutis,  or  an  Instrument  to  Cleanse  the  Stomach," 
1649. 

18.  Sorbierus,  in  "  Sorberiana,"  Paris,  1694. 

19.  Pechlini,  Joh.  XicoL,  "Observation,  physico-medical.,"  liber  I,  observ. 
50,  S.  116,  Hamburg,  1691. 

20  J.  C.  Socrates,  "  Griindliche  u.  vollstandige  Beschreib.  d.  Peniculi  Ventri- 
culi  Singularis,"  etc.,  Lips.  u.  Frankfurt,  1713;  "  Breslauer  Sammlung  von 
Natur  u.  ^.ledizin,"  etc.  ;   "  Geschichten,"  1719,  Classe  v,  Art.  iii. 

21.  Abercrombie,  "Diseases  of  the  Stomach." 

22.  Capivacceus,  Hieronymus,  "]\Iedic.  practic,"  liber  I,  cap.   H,  Venice, 

1598. 

23.  Van  Helmont,  "  Doctrina  inaudita  de  causa,"  etc.,   "  Lithiasis,"   1646, 

Cap.  VII,  34,  S.  140. 

24.  John  Hunter,  "Proposals  for  the  Recovery  of  People  Apparently 
Drowned,"  "Sammlung  auserlesener  Abhandlungen,"  iv,  S.  144. 

25.  Moritz,  Zeitschrift  f.  Biologie,  xxxil,  p.  314,  Leipzig,  1895. 

26.  Martius  and  Liittke,  "Die  IMagensaure,"  Stuttgart,  1892. 

27.  F.  Penzoldt,  "Allgem.  Behandl.  d.  ]\Iagen-  u.  Darmkrankheiten,"  in 
"  Handbuch  der  speciell.  Therapie  innerer  Krankh.,"  vol.  iv,  p.  289. 

28.  Ewald,  "  A  Ready  ?vIethod  of  Washing  Out  the  Stomach,"  Irish  Gazette, 
August  15,  1874. 


Il6  ■      BIBLIOGRAPHY. 

29.  Jurgensen,  "  Zur  lokal.  Therapie  der  Magenkrankheiten,"  Deutsch. 
Archivf.  klin.  Medizin,  Bd.  vir,  p.  239,  1870. 

30.  Ploss,  "  Der  Magencatheter  a  double  courant,"  etc.,  Deutsche  Klinik, 
1870,  No.  8. 

31.  Hemmeter,  John  C,  "  An  Apparatus  for  Washing  Out  the  Stomach  and 
Sigmoid  with  a  Continuous  Current,"  etc.,  New  York  Med.  Jour.,  March  30, 
1895. 

32.  Penzoldt,  Franz,  "  Die  Magenerweiterung,"  Erlangen,  1875. 

33.  Leube,  Deulsch.  Arch.f.  klin.  Med.,  Bd.  33. 

34.  Jackson,  Extracts,  Records  of  the  Boston  Society  for  Medical  Improve- 
ment, vol.  VI,  p.  261. 

35.  Welch,  William  H.,  "Pepper's  American  System  of  Medicine,"  vol.  11, 
p.  607. 

36.  Rosenheim,  "  Krankheit.  d.  Speiserohre  u.  d.  Magens,"  Wien  u. 
Leipzig,  1 89 1. 


CHAPTER  XIII. 

METHODS  FOR  QUALITATIVE  AND  QUANTITATIVE 
ANALYSIS  OF  STOMACH  CONTENTS. 

Presence  of  Bits  of  Gastric  Mucosa. — Exavtiiiation  of  StomacJi  Con- 
tents for  Mucus,  Saliva,  Bile,  Duodenal  Secretions,  Blood,  and 
Pus. —  Tests  for  Blood  in  Stomach  Contents. — Demonstra- 
tion of  the  Presence  of  Iroii  in  Stomach   Contents  or 
Vomited  Matter. — Spectroscopic   Examination    of 
Stomach   Contents  for  Blood. — Examination 
of  Portions  of  Mucosa  or   Tissue  found 
in    the     Wash-water   or    Vomited 
Matter. — Literature. 

The  stomach  contents  should  be  examined  for — 

1.  The  character  and  amount  of  the  undigested  food. 

2.  The  presence  and  kind  of  bacteria. 

3.  The  bile,  mucus,  pus,  and  blood. 

4.  The  total  acidity. 

5.  The  amount  of  free  hydrochloric  acid. 

6.  The  presence  of  jjTorganic,  lactic,  butyric,  or  acetic  acids. 

7.  The  combined  hydrochloric  acid  and  acid  salts. 

8.  The  presence  of  products  of  digestion,  viz.,  syntonin,  pro- 
peptone,  albumoses,  peptone. 

9.  The  presence  of  pepsin  and  rennin ;  if  these  are  absent,  their 
pro-enzymes. 

10.  The  products  of  starch  digestion,  dextrin,  erythrodextrin, 
achroodextrin,  and  maltose, 

11.  Fragments  of  mucosa. 

12.  Fragments  of  neoplasms. 

Character  and  Amount  of  Undigested  Food. — The  exam- 
ination for  undigested  food-particles  may  demonstrate  the  presence 
of  substances  eaten  twenty-four  hours  before  the  expression  of 
contents,  and  thus,  at  once,  establish  a  dilatation  or  stenosis.  As 
already  pointed  out,  excess  of  rice  and  bread,  and  absence  of  beef 

117 


Il8  ANALYSIS    OF    STOMACH    CONTENTS. 

and  egg,  indicates  a  higher  acidity,  while  absence  of  bread  and 
rice,  and  presence  of  egg  and  beef,  indicates  sub-  or  anacidity. 
This,  of  course,  can  be  most  conveniently  studied  when  the  contents 
are  drawn  out  about  five  hours  after  the  double  meal,  as  employed 
at  the  Maryland  General  Hospital. 

Bacteria. — For  bacteriological  examination,  a  (e\v  slides  are 
stained  with  methylene  blue,  and,  also,  cultures  made,  the  latter 
especially  when  there  is  any  disease  of  the  air-passages,  the 
microbes  of  which  may  get  into  the  stomach  with  swallowed  mucus 
or  run  down  unconsciously  during  sleep.  This  is  particularly 
important  in  pulmonary  or  laryngeal  tuberculosis.  Instead  of 
methylene  blue,  Lugol's  solution  of  iodin  should  be  used  on  other 
slides  for  examining  bits  of  tissue,  mucosa,  and  cellular  detritus. 

The  normal  stomach  contains  many  micro-organisms;  only 
very  large  numbers  of  bacteria  have  a  pathological  significance  if 
by  culture  experiments  they  can  be  shown  to  be  still  capable  of 
multiplication. 

Microbes  only  propagate  luxuriantly  when  stagnation  of  gastric 
contents  occurs.  The  secretory  disturbances  are  then  a  secondary 
effect,  a  consequence  of  the  stagnation.  But  primary  reduction  of 
HCl  secretion  has  been  known  to  cause  a  luxuriant  gastric  flora, 
since  it  is  the  HCl  which,  to  a  great  extent,  inhibits  their  develop- 
ment and  also  destroys  a  large  number  of  them.  If  there  be 
deficient  peristaltic  power,  the  diminution  of  HCl  causes  further  dis- 
turbances in  the  stomach  and  intestines  by  accumulation  of  bac- 
teria. But  no  degree  of  gastric  acidity,  no  matter  how  great,  can 
destroy  all  bacteria  introduced. 

Hyperacidity  is  as  detrimental  in  its  consequences  as  anacidity, 
because  it  inhibits  normal  intestinal  digestion,  which  is  the  best 
means  of  combating  fermentation  and  putrefaction.  Hydrochloric 
acid  undoubtedly  inhibits  or  checks  gastric  fermentation  to  a  cer- 
tain extent,  but  all  ferment-producing  microbes  are  not  destroyed 
by  it  in  the  stomach.  Therefore,  one  frequently  finds  gastric 
fermentation  with  hyperacidity  of  HCl,  and,  reversely,  fermenta- 
tion may  be  absent  where  hydrochloric  acid  is  entirely  absent, 
provided  the  motility  is  good. 

This  will  again  impress  the  importance  of  an  intact  gastric  peris- 
talsis, a  certain  time  of  action  being  indispensable  for  organized 
ferments  to  set  up  their  characteristic  decomposition  even  at  the 
body   temperature;    with    a    good   motility,   however,   the   gastric 


OPPLER-BOAS    BACILLUS. 


119 


chyme  may  reach  the  intestine,  meeting  a  vigorous  digestion 
before  the  bacteria  get  a  chance  to  forge  ahead  of  the  normal  unor- 
ganized ferments. 

The  most  frequent  of  fungi  in  gastric  contents  is  ordinary  yeast, 
and  there  should  be  no  difficulty  in  recognizing  it ;  unless  occur- 
ring in  very  large  numbers,  it  has  no  pathological  significance.  Two 
more  germs  found  in  the  contents  are  of  interest — the  sarcinae  and 
the  Oppler-Boas  bacillus,  the  latter  occurring  in  the  gastric  contents 
of  carcinoma.  Sarcinse  may  be  seen  under  the  microscope  without 
staining;  they  are,  indeed,  preferably  to  be  examined  that  way,  as 
they  stain  so  deeply  with  anilin  dyes  as  to  look  like  black  patches. 

Sidney  Martin  recommends  drying  and  fixing  a  drop  of  stomach 
contents  on  the  slide  or 
cover-glass,  and  placing  in  a 
very  dilute  solution  of  gentian 
violet  for  -three  minutes, 
washing  out  in  water  and 
mounting  in  Canada  balsam. 
The  gentian  violet  must  be 
so  diluted  as  to  be  nearly 
transparent.  Yeast  can  simi- 
larly be  stained  by  magenta 
or  methylene-blue  solution 
(two  per  cent.).  If  the  latter 
is  used,  the  preparation  re- 
quires washing  out  in  water. 

Sarcinae  can  hardly  be  said 
to  have  any  pathological  significance,  according  to  Oppler  (^MuncJien. 
Med.  Wochenschr.,  1894,  No.  29).  They  are  found  in  ectasias,  occur- 
ring on  a  non-malignant  basis,  and  in  very  atonic  conditions ;  also 
in  acute  and  chronic  gastritis,  in  ulcer,  in  the  gastric  neuroses,  and 
the.  gastroptoses. 

Riegel  agrees  with  Oppler  in  the  assertion  that  sarcinae  are  very 
rarely  found  in  gastric  carcinoma.  They  are  generally  observed 
in  biscuit  or  bale-shaped  groups  of  four,  eight  and  16  individual 
sarcinae  bunched  together;  their  occurrence  as  single  individuals  is 
seen  rarely. 

The  Oppler-Boas  bacillus  (Oppler,  "  Zur  Kentniss  d.  Magenin- 
halts  bei  Carcinoma  YentvicnYi,"  De^itsche  Aled.  Wochenschr.,  1895, 
No.  5)  is  an   unusually  long  and  non-motile  bacterium,  which  was 


Fig.  19. — Oppler-Boas   Bacillus  from    Contents 
OF  A  Carcinomatous  Stomach. 


I20  ANALYSIS    OF    STOMACH    CONTENTS. 

observed  in  many  cases  of  gastric  carcinoma  (see  Fig.  19).  In  20 
cases  of  carcinoma,  Kaufmann  found  these  bacilli  19  times,  and, 
according  to  his  investigations,  they  have  the  power  of  abundantly 
forming  lactic  acid  from  various  kinds  of  sugar.  In  the  only 
case  of  the  20  just  mentioned  in  which  the  Oppler-Boas  bacilli 
was  absent,  the  lactic  acid  was  absent  also. 

According  to  Schlesinger  and  Kaufmann  ( JVtcner  KliniscJie  Rund- 
schau, 1895,  No.  15),  the  presence  of  a  large  number  of  these  bacilli 
in  the  stomach  contents  is  an  indication  of  carcinoma,  and  their 
absence  is  of  similar  significance  to  the  absence  of  lactic  acid.  If 
a  stenosis  of  the  pylorus  is  present,  then  the  absence  of  these  bacilli 
is  an  argument  against  carcinoma.  Riegel  iloc.  cit?)  confirms  the  oc- 
currence of  these  bacilli  in  enormous  numbers  in  carcinoma,  and 
adds  that,  although  there  are  numerous  fungi  that  have  the  prop- 
erty of  forming  lactic  acid  in  stomach  contents,  this  can  not  alter 
the  significance  of  the  Kaufmann  and  Schlesinger  observation.  He 
does  not  consider  these  organisms  as  pathognomonic  of  gastric 
cancer,  but  as  very  important  for  the  diagnosis. 

Our  knowledge  concerning  the  bacteria  occurring  in  normal  and 
pathological  stomach  contents  is  very  incomplete  as  yet.  It  ap- 
pears, however,  that  in  all  pathological  processes  we  are  not  con- 
fronted with  qualitatively  new  bacteria,  but  with  excessive  multi- 
plication of  those  normally  present.  The  disturbances  produced 
by  abnormal  augmentation  of  bacteria  in  the  stomach  are  ex- 
plained by  Minkowski  ("  Ueber  d.  Gahrung  im  Magen,"  Mittheilung 
a.  d.  Medic.  Klin.  Konigsberg,  edited  by  B.  Naunyn,  Leipzig, 
1888,  S.  156)  in  the  following  manner: 

1.  Substances  ma}'  be  formed  which  irritate  the  mucosa  and  pro- 
voke catarrhal  inflammation. 

2.  Gas  may  be  formed  in  considerable  quantities,  causing  dis- 
tress by  distention,  and  increase  the  mechanical  insufficiency 
already  present. 

3.  The  fermentation  may  give  rise  to  toxins. 

4.  Putrefaction  of  albuminous  bodies  may  produce  alkaline 
bodies  that  will  neutralize  the  hydrochloric  acid  or  what  little  of  it 
may  yet  be  secreted. 

5.  Gastric  fermentations  may  have  a  detrimental  influence  on  the 
intestinal  functions. 

Examination  of  Stomach  Contents  for  Mucus,  Saliva,  Bile, 
Duodenal  Secretions,  Blood,  and  Pus. — The  presence  of  mucus  is 


TESTS    FOR    SALIVA    AND    BILE    IN    GASTRIC    CONTENTS.  121 

evident  to  the  naked  eye  by  its  stringy  and  tenacious  character.  Its 
chemical  demonstration  is  carried  out  by  dissolving  the  mucus  in 
liquor  potassae,  in  which  it  is  slightly  soluble,  and  from  which  it  can 
be  reprecipitated  by  acetic  acid.  When  pharyngitis,  laryngitis,  and 
bronchitis  can  be  excluded,  large  quantities  of  mucus  in  stomach 
contents  are  indicative  of  gastritis. 

If  the  gastric  contents  consist  largely  of  saliva,  this  can  be 
demonstrated  by  the  potassium  sulphocyanate,  otherwise  known 
as  rhodankalium,  KCNS,  which  is  a  normal  constituent  of  healthy 
saliva.  Potassium  sulphocyanate  gives  a  dark,  purplish-red  color 
upon  the  addition  of  a  solution  of  chlorid  of  iron. 

Bile,  if  present  to  any  considerable  extent,  is  noticeable  at  once 
to  the  naked  eye  by  the  compound  greenish-yellow  tinge  it  im- 
parts to  stomach  contents.  Very  slight  amounts  of  bile  and 
duodenal  secretions  are  occasionally  observed  under  normal  con- 
ditions, particularly  if  the  stomach  be  washed  out  early  in  the 
morning  before  breakfast,  for  there  is  no  absolute  closure  of  the 
pylorus  when  the  stomach  is  empty. 

Boas  has,  however,  pointed  out  that  constant  presence  of  very 
evident  admixture  of  bile  and  duodenal  secretions  points  to  stenosis 
of  the  descending  portion  of  the  duodenum  (Boas,  Deiitsclie  med. 
Wochenschr.,  1791,  No.  28.,  "  Ueber  die  Stenose  des  Duodenum  "). 
As  a  rule,  it  will  be  necessary  to  assure  oneself  of  the  presence  of 
bile  by  the  Gmelin  test,  or  the  demonstration  of  bile  acids  or  cho- 
lesterin. 

Gmelin's  test  is  carried  out  by  adding  20  drops  of  fuming  nitric 
acid  to  10  c.c.  of  officinal  nitric  acid  in  a  test-tube.  Ten  c.c.  of 
stomach  filtrate  are  drawn  into  a  pipette,  and,  holding  the  test-tube 
with  the  HNO3  in  the  left  hand  in  a  slanting,  horizontal  position, 
the  filtrate  is  allowed  to  flow  slowly  from  the  pipette  held  in  the 
right  hand  over  the  nitric  acid.  If  the  stomach  contents  contain 
bile,  there  will  be  formed  several  characteristic  rings  of  color, 
which,  going  from  above  downward,  are  (i)  green,  (2)  blue, 
(3)  violet,  and  (4)  red,  but  only  the  green  color  is  an  evidence  of  the 
presence  of  bile. 

Better  results  are  obtained  by  using  a  conical  glass  on  a  broad 
foot  instead  of  a  test-tube.  In  the  clinical  laboratory  they  are  of 
60-79  c-c,  or  about  two  ounces  in  capacity.  It  is  of  some  advantage 
to  be  able  to  place  them  alternately  on  and  in  front  of  a  white  and 
black  background  during  the  reaction.  First,  20  c.c.  of  gastric  juice, 
9 


122  TESTS    FOR    BILE,    ACIDS    AND    BLOOD. 

if  necessary  previously  filtered,  are  placed  in  the  glass,  then  ten  c.c. 
of  nitric  acid  added  by  a  pipette,  which  is  carefully  carried  to  the 
bottom  of  the  vessel ;  here  the  nitric  acid  is  very  gradually  per- 
mitted to  escape  by  diminishing  the  pressure  of  the  finger  on  the 
end  of  the  pipette.  In  this  manner  it  is  easier  to  get  the  nitric  acid 
under  the  gastric  juice.  The  display  of  the  colors,  yellow,  green,  blue, 
violet,  and  red,  occurs  from  above  downward  ;  the  green  color  is  the 
only  one  that  is  characteristic  of  bile  elements. 

The  demonstration  of  the  bile  acids  is  effected  by  first  precipitating 
all  albuminous  bodies  by  boiling  or  by  alcohol ;  a  few  drops  of  a 
solution  of  cane  sugar  are  added,  and  then,  drop  by  drop,  pure  con- 
centrated sulphuric  acid.  If  the  solution  is  now  heated  a  beautiful 
purple-red  color  is  obtained,  between  60°  and  70°  C.  (Pettenkofer). 

The  presence  of  duodenal  secretions  is  demonstrated  by  test- 
ing the  stomach  contents  for  the  specific  ferment  activity  of 
trypsin,  amylopsin,  and  steapsin.     (See  p.  58.) 

Tests  for  Blood  in  Stomach  Contents. — Although  blood  may 
be  present  in  the  material  drawn  by  a  stomach-tube,  or  in  vomit,  it  is 
not  always  easy  to  decide  whether  it  was  derived  from  the  lungs  or 
from  the  stomach.  Vomiting  may  produce  a  cough,  and,  vice  versa, 
coughing  may  lead  to  an  attack  of  vomiting,  and  in  cases  where 
either  organ  is  liable  to  hemorrhage,  as  in  tuberculous  patients  with 
a  congestive  state  of  the  mucosa,  it  is,  except  in  rare  instances, 
impossible  to  decide  the  origin  of  the  blood. 

In  cases  with  copious  arterial,  gastric  hemorrhage,  the  blood 
is  bright  red  and  clotted.  A  slower  but  still  quite  profuse  hemor- 
rhage generally  shows  as  a  black  clot  or  mass  of  black  clots.  In 
very  slow  but  continuous  hemorrhage  the  blood  collects,  and  may 
be  partially  digested  or  decomposed  in  the  stomach  before  it  is 
vomited  as  a  black,  coffee-ground  material.  The  diagnosis  of 
blood  in  the  vomit  is  not  always  easily  made.  There  are  four 
methods  of  determining  the  presence  of  blood,  and  by  one  or  more 
of  them  it  may  generally  be  accomplished. 

The  first  is  by  the  microscopical  demonstration  of  the  red  blood- 
corpuscles.  In  cases  of  suspected  ulcer,  all  vomited  matter  should 
be  microscopically  examined,  even  when  blood  is  not  evident  to  the 
naked  eye. 

The  second  is  known  as  the  guaiacum  test.  Two  or  three  drops 
of  freshly  prepared  tincture  of  guaiacum  are  added  to  five  c.c.  of 
stomach  contents  in  a  test-tube,  and  ozonized  ether  poured  on  the 


GUAIACUM    TEST — HEMIN    CRYSTALS.  I  23 

surface  ;  if  blood  is  present,  a  blue  color  develops  where  the  two 
liquids  meet.  Equal  parts  of  tincture  of  guaiacum  and  turpentine 
that  have  been  exposed  to  the  air  may  be  used  instead  of  ether. 
This  test  for  blood  is  fallacious,  as  almost  any  carbohydrate,  bile, 
or  saliva  will  produce  the  same  color  in  the  total  absence  of  blood. 

The  guaiacum  test,  which  was  originally  proposed  by  Almen  and 
van  Deen,  becomes  more  reliable  when  executed  by  an  improved 
method  suggested  by  H.  Weber.  A  considerable  quantity  of  the 
filtrate  is  extracted  or  mixed  with  water  ;  glacial  acetic  acid,  to  the 
amount  of  one-third  of  the  entire  quantity  of  water  and  filtrate 
mixture,  must  be  added. 

Of  this  acid  extract,  about  ten  c.c.  are  poured  off  after  settling  ; 
then  ten  drops  of  tincture  of  guaiacum  and  20  to  30  drops  of  tur- 
pentine are  added.  If  blood  is  present,  the  mixture  becomes 
violet-blue;  in  case  blood  is  absent,  the  color  will  be  red-brown. 
The  blue  coloring  matter  that  indicates  blood  can  be  extracted  by 
shaking  the  mixture  with  chloroform.  Coffee-ground  vomit  will 
not  permit  of  the  correct  finding  of  blood  with  either  of  the  two 
preceding  tests. 

This  kind  of  vomit  may  have  to  be  differentiated  from  genuine 
tea  or  coffee  vomit,  or  from  bile,  by  Gmelin's  test.  In  this  form  of 
vomit,  the  corpuscles  are  disintegrated  and  the  hemoglobin  trans- 
formed into  insoluble  hematin.  Still,  there  are  two  ways  left  to 
diagnose  the  blood  present,  if  any :  first,  the  formation  of  crystals 
of  hemin,  and,  secondly,  the  demonstration  of  the  presence  of  iron. 

1.  Preparation  of  hemin  crystals:  Three  to  four  drops  of  the  thick 
sediment  is  mixed  on  a  glass  slide  with  a  little  common  salt,  then 
one  to  two  drops  of  glacial  acetic  acid  are  added,  and  the  mixture 
carefully  heated  over  a  small  flame  of  a  spirit-lamp  or  a  Bunsen 
burner  until  bubbles  begin  to  form.  If  blood  is  present,  on  exam- 
ining the  preparation  with  the  microscope,  reddish-brown,  oblong 
crystals  of  hemin  hydrochlorate  will  be  recognized:  their  color, 
form,  and  occurrence  is  characteristic.  This  test  may  fail  in  cases 
where  blood  is  present. 

2.  Demonstration  of  the  presence  of  iron:  Naturally,  the  patient 
whose  stomach  contents  are  to  be  examined  must  not  have  been 
taking  iron  in  any  form,  nor  any  raw  meats. 

Demonstration  of  the  Presence  of  Iron  in  the  Stomach  Con- 
tents or  in  Vomited  Matter. — In  case  one  is  dealing  with  coffee- 
ground  material  this  test  may  become  necessary.    Some  of  the  black 


124  SPECTROSCOPIC    EXAMINATION    FOR    BLOOD. 

sediment  is  placed  in  a  porcelain  dish,  and  a  few  crystals  of  potassium 
chlorate  and  two  to  three  drops  of  strong  hydrochloric  acid  are 
added.  On  heating  over  a  flame  and  adding  a  few  drops  of  a  five 
per  cent,  solution  of  potassium  ferrocyanid,  4KCN,  Fe(CN)24  H2O, 
Prussian  blue  will  be  formed.  Boas  and  Sidney  Martin  consider 
this  a  very  delicate  test.  The  Prussian  blue,  upon  the  occurrence 
of  which  this  test  depends,  is  a  complex  c\'anid  of  iron,  4Fe(CN);j. 
3Fe(CN),. 

Spectroscopic  Examination  of  Stomach  Contents  for  Blood. 
— A  spectroscopic  examination  is  possible  when  the  red  blood- 
corpuscles  have  become  dissolved,  and  the  filtrate  of  gastric  con- 
tents contains  oxyhemoglobin.  The  compound  of  oxygen  with 
hemoglobin  is  distinguished  by  two  absorption  bands  in  the  spec- 
trum, which  occur  between  the  Fraunhofer  lines  D  and  E  in  the 
yellow  and  green.  If  after  the  recognition  of  these  lines  a  reducing 
agent  is  added  to  the  solution  of  oxyhemoglobin,  for  instance,  if 
it  is  shaken  with  ammonium  sulphid,  the  two  bands  observed  be- 
fore fuse  into  a  single  broad  band,  occupying  the  space  between  the 
two  distinct  and  separate  bands,  or  move  beyond  D  toward  the  red  of 
the  spectrum.  (Compare  Eichhorst,  loc.  cit.  p.  523  ;  also  Richard 
C.  Cabot,  "  Clinical  Examination  of  the  Blood,"  Wm.  Wood&  Co., 
Publishers,  New  York,  1897,  and  von  Jaksch,  loc.  cit.) 

Examination  of  Portions  of  Mucosa  or  Tissue  Found  in  the 
Washwater  and  in  Vomited  Matter. — In  the  washwater  from 
almost  every  stomach,  also  in  the  samples  of  test-meals  gained  by 
the  Ewald  expression  method,  and  in  vomited  matter,  small  portions 
of  the  superficial  mucosa  of  the  stomach  can  frequently  be  found 
on  careful  searching.  Stimulated  by  reading  the  accompanying 
literature,  particularly  the  work  of  Hayem,  Boas,  Einhorn,  and 
Cohnheim,  we  have  during  the  last  three  years  made  a  study  of 
such  tiny  bits  of  mucosa. 

To  detect  them  more  easily,  the  stomach  is  best  washed  in  the 
morning,  before  breakfast,  with  500  c.c.  of  warm  water,  which  is 
poured  into  a  shallow  papier-mache  or  hard  rubber  dish,  the  bot- 
tom of  which  is  colored  white  and  black;  on  this  background  the 
tiny  bits  of  tissue  from  the  mucosa,  or  from  any  neoplasm  that  may 
be  in  the  stomach,  can  be  more  easily  recognized.  These  particles 
are  usually  of  a  reddish  color ;  they  may  seem  at  times  colorless, 
so  that  in  a  glass  or  pitcher  they  may  be  overlooked,  while  on  the 
dark  flat  dish  they  are  quite  apparent.     These  fragments  come  from 


FRAGMENTS    OF    MUCOSA.  1 25 

very  superficial  erosions,  which  are  possibly  caused  by  very  slight 
local  congestions  or  by  traumatism  (Ewald,  loc.  cit). 

It  is  conceivable  that  the  contractions  of  the  muscularis  of  the 
stomach  may,  if  sufficiently  powerful,  effect  an  arrest  of  the  flow  of  cir- 
culation in  the  folds  and  cause  intense  congestion  of  the  veins  and  cap- 
illaries, which  may  give  rise  to  small  hemorrhages  into  the  mucosa. 
These  hemorrhagic  areas  are  very  poorly  nourished  by  the  blood- 
current,  and  may  eventually  succumb  to  theautodigestive  action  of 
the  gastric  juice  ;  other  gastric  contractions  then  loosen,  and  cast  off 
these  tiny  spots  of  necrosis  (Hartung,  loc.  cit.). 

According  to  Virchow  {loc.  cit^,  circulatory  derangements  of  the 
larger  vessels  of  the  stomach — the  acute  and  chronic  gastritis  espe- 
cially— if  accompanied  with  vomiting  and  colicky  contractions,  are 
the  cause  of  ulcers  and  erosions.  Small  erosions  represent  only  the 
superficial  stratum  of  the  mucosa,  generally  only  the  vestibule  or 
alveolus  and  the  first  third  of  the  gland-ducts  ;  the  entire  lower  half 
of  the  mucous  membrane  is  not  cast  off  (Gerhardt, /(?^.  rz/.).  The 
gland-duct  remaining  shows  nothing  pathological.  At  the  sides 
and  edges  the  glands  become  longer,  and  the  first  ones  that  are 
intact  usually  curve  themselves  over  the  defect,  partly  covering  it. 
Recovery  takes  place  by  the  simple  after-growth  of  the  remaining 
portions  of  the  glands. 

In  three  stomachs  which  were  taken  immediately  after  death 
(not  later  than  two  hours  after),  we  observed  what  was  undoubtedly 
a  superficial  epithelial  sequestrum  resting  loosely  upon  the  mucous 
membrane  in  many  places  of  what  we  had  every  reason  to  believe 
was  a  perfectly  normal  stomach.  The  autodigestion  in  this  case 
had  been  prevented  by  pouring  80  per  cent,  alcohol  into  the  organ 
about  fifteen  minutes  after  death.  In  places,  portions  of  mucosa 
half  as  large  as  a  lentil  seed  could  be  dislodged  by  a  gentle  stream 
of  water  from  a  wash-bottle.  The  erosions  included  the  inner  third 
of  the  gland-duct  proper  (inneres  Schaltstiick  of  Stohr),  and  it  seems 
that  even  before  they  were  dislodged  the  process  of  repair  had 
already  begun ;  for  underneath  small  areas  of  necrosed  super- 
ficial epithelium  that  were  lifted  from  the  true  glandular  stratum  by 
a  thin  layer  of  lymph  containing  {qvj  red  blood-corpuscles,  cell 
proliferation  was  going  on  in  the  parietal  or  oxyntic  cells,  and  in 
the  cylindrical  cells  of  the  adjoining  intact  epithelium,  formation  of 
mitosis  and  karyokinetic  figures  were  evident  in  picrocarmin  and 
eosin  stains  of  these  sequestrations  of  mucosa. 


126  .  CAUSES    OF    GASTRIC    EXFOLIATION. 

It  seems  possible  that  a  process  of  exfoliation  is  constantly  going 
on  in  the  lining  membrane  of  the  gastro-intestinal  tract  just  as  in 
the  epidermis.  It  is  not  conceivable  that  the  constant  and  con- 
tinuous impact  and  friction  of  the  ingesta  should  go  on  daily 
without  causing  necrosis  of  epithelium  in  places.  If  we  should 
hold  the  normal  acid  chyme  in  the  palm  of  our  hands  for  three  or 
four  hours  three  times  or  more  every  day,  we  would  very  soon 
notice  exfoliations  of  the  epidermis. 

In  the  digestive  tract  (for  it  occurs  all  along  the  small  intestine) 
this  exfoliation  goes  deeper  than  in  our  hands  because  of  imme- 
diate autodigestion  of  the  exfoliated  spot.  Although  we  have 
examined  nearly  50  human  stomachs  with  especial  regard  for  this 
phenomenon,  we  have  failed  to  detect  it  in  but  four  cases,  and 
in  these  the  examination  was  limited  to  a  very  small  portion  of 
the  stomach. 

Even  in  stomachs  obtained  within  one  hour  after  death,  and 
preserved  by  pouring  alcohol  or  solutions  of  formalin  into  the 
organ,  these  erosions  can  be  seen  in  places.  We  generally  request 
a  strip  which  begins  in  the  esophagus,  runs  through  the  cardia 
saccus  coecus,  entire  greater  curvature,  and  pylorus,  and  has  a  piece 
of  duodenum  attached  to  it.  This  is  hardened,  and  in  many 
places  pieces  are  excised  half  an  inch  apart  and  imbedded  in  cel- 
loidin,  and,  cut  into  serial  sections  with  the  revolving  microtome, 
stained  in  eosin  and  hematoxylin  and  mounted  in  balsam.  In 
some  cases  we  sectioned  strips  running  along  the  lesser  curvature. 

In  this  way  it  was  found  that  most  of  these  erosions  and  exfolia- 
tions occur  in  the  vicinity  of  the  sphincter  antri  pylorici,  about 
seven  to  ten  cm.  from  the  pylorus.  At  this  point  the  muscu- 
laris  has  its  most  powerful  development,  and  the  peristalsis,  and 
consequently  the  impact  of  the  food  with  the  mucosa,  is  most 
vigorous;  hence  the  epithelium  here  has  most  to  suffer  from  fric- 
tion. Slight  erosions  can  be  detected  in  the  lower  part  of  the 
esophagus,  where  no  peristalsis  normally  occurs  but  that  accom- 
panying deglutition.  So  the  conclusion  seems  justifiable  that  very 
tiny  exfoliations  and  erosions  occur  in  all  stomachs,  and,  in  adult 
life,  perhaps  at  all  times.  This  precludes  the  presumption  that  the 
pieces  of  mucosa  are  lesions  produced  by  the  stomach-tube. 

Boas  {loc.  cit.)  thinks  that  coughing  or  defecation  may  cause  the 
dislodgment  of  such  loosened  epithelium.  When  this  process 
reaches  such  an  exaggerated  type  as  described  by  Einhorn  {loc.  cit., 


LITERATURE    OX    EROSIONS.  12/ 

"  Erosions  of  the  Stomach  "),  it  is  very  probable  that  the  mucosa  is 
made  less  resistant  by  some  well-developed  gastric  disease  (one  of 
the  forms  of  gastritis,  carcinoma,  etc.),  for  his  patients  suffered 
from  pains,  emaciation,  and  weakness. 

Among  the  46  stomachs  examined  by  myself  were  19  in  which 
no  symptoms  referable  to  the  stomach  were  given  during  life. 
The  pieces  varied  from  five  mm.  in  length,  and  nearly  as  wide.  Ein- 
horn  recommends  intragastric  spraying  of  a  solution  of  i  :  looo 
of  argentic  nitrate  for  the  excessive  exfoliation,  combined  with 
intragastric  galvanization,  diet,  and  tonics,  with  a  hygienic  out- 
door life. 

LITERATURE 

O.V   EXFOLIATIONS    AND    EROSIONS    OF   GASTRIC    MUCOSA. 

Hayem,  "Gastritis  Parenchymatosa,"  Allg.  Wien.  Med.  Zeiiung,  1894, 
p.  2-17. 

Cramer,  "  Ueber  d.  Ablosung  d.  Magenschleimhaut  durch  die  Sondirung," 
Munch.  Med.  Woch.,  p.  52,  1891. 

Korczynski  u.  Jaworski,  "  Klinische  Befunde  bei  Ulcus  u.  Carcinoma 
Ventriculi,"  etc.,  Deutsche  Men.  Woch.,  p.  47-49,  1886. 

Ebstein,  "  Ueber  die  Losung  eines  Stiickes  d.  Pylorusschleimhaut  mit  d. 
Magensonde,"  Berlin,  klin.  Woch.,  1895. 

Einhorn,  "  Clinical  Observations  on  Erosions  of  the  Stomach  and  their 
Treatment,"  N.   V.  Medical  Record,  June  23,  1894. 

Einhorn,  "State  of  the  Gastric  Mucosa  in  Secretory  Disorders  of  the 
Stomach,"  New  York  Medical  Record,  June  27,  1866. 

Evvald,  "  KHnik  d.  Verdauungskrankheiten,"  3d  edit.,  p.  191. 

Boas,  "  Diagnostik  u.  Therap.  d.  Magenkrankh.,"  Allg.  Th.,  3d  ed.,  p.  220. 

Hayem,  "  Resume  de  I'Anatomie  Pathologique  de  la  Gastrite  Chronique," 
Gaz.  Hebdom.,  p.  33-34,  1892. 

Damaschino,  "  Note  sur  un  nouveau  procede  pour  I'etude  de  lesions  de 
I'estomac,"  Gaz.  tned.,  1880. 

Schmidt,  "  Ein  Fall  von  Magenschleimhautatrophie  nebst  Bemerkungen 
iiber  die  sogenannte  schleimige  Degeneration  der  Driisenzellen  des  Magens," 
Deutsche  med.  Woch.,  19,  1895. 

Rosenheim,  "  Ueber  atrophische  Processe  an  der  Magenschleimhaut  in  ihrer 
Beziehung  zum  Carcinom  u.  als  selbststandige  Erkrankung,"  Berl.  klin.  Woch., 
51,  1881. 

Jaworski  u.  Korcynski,  "  Ueber  einige  bisher  wenig  beriicksichtigte  khnische 
und  anatomische  Erscheinungen  im  Verlaufe  des  sogenannten  Magenkatarrhs," 
Arch.  f.  klin.  Med.,  47,  p.  578. 

Meyer,  "  Zur  Kenntniss  der  sogenannten  ]\Iagenatrophie,"  Zeitsch.f.  klin. 
Med.,  Bd.  xvi,  p.  366. 

Hammerschlag,  "  Zur  Kenntniss  des  Magencarcinoms,"  Wiener  klin. 
Rundschau,  23,  1895. 


128  LITERATURE    ON    EROSIONS. 

Sachs,  "  Zur  Kenntniss  der  Magenschleimhaut  in  krankhaften  Zustanden," 
Archiv  f.  exp.  Pharm.  u.  Pathol.,  Bd.  24,  1888. 

Stintzing,  "  Zum  feineren  Bau  u.  zur  Physiologic  d.  Magenschleimhaut," 
Milnchener  med.  Woch.,  \(i,  1889. 

Kupfifer,  "  Epithel  u.  Diiisen  d.  menschlichen  Magens,"  Miinchen,  1883. 

Ebstein,  "  Beitrage  zur  Lehre  vom  Bau  der  sogenannten  Magenschleim- 
drusen,"  Schullzes  Arch.,  Bd.  vi,  p.  530. 

Stohr,  "  Zur  Kenntniss  des  feineren  Baues  der  menschlichen  Magenschleim- 
haut," Schiiltzes  Arch.,  Bd.  xx,  p.  221. 

Boas,  "  Ueber  Gastritis  acida,"   Wiener  med.  Woch.,  1-2,  1895. 

Klemperer,  "Ueber  die  Dyspepsie  der  Phthisiker,"  Berlin,  klin.  Woch.,  11, 
1889. 

Schmidt,  "  Fortgesetzte  Untersuchungen  iiber  die  Secretion  des  Magen- 
schleims,"  Deutsche  med.  Woch.,  Vereinsbeilage ,  13,  1895. 

Einhorn,  "Zur  Achylia  gastrica,"  Arch.  f.  Verdatatngskrattkh.,  Bd.  i. 
Heft  2. 

Boas,  "  Beitrag  zur  Symptomatologie  des  chronischen  Magenkatarrhs  und 
der  Atrophie  der  Magenschleimhaut,"  Miinch.  vied.  Woch.,  41  u.  42. 

Ewald,  "Ein  Fall  chronischer  Sekretionsuntiichtigkeit  des  Magens"  (Ana- 
denia  ventriculi  ?),  "  Das  Benzonapthol,"  Berl.  klin.  Woch.,  26  u.  27,  1892. 

Fenwick,  "  Ueber  den  Zusammenhang  einiger  krankhafter  Zustande  des 
Magens  mit  anderen  Organerkrankungen,"   Virch.  Archiv,  Bd.  118,  Xll. 

Ewald,  "  Ein  Fall  v.  Atrophie  d.  Magenschleimhaut  mit  Verlust  d.  HCl 
Sekretion  Ulcus  carcinomatosum  duodenale,"  Berlin,  klin.  Woch.,  1886. 

Gerhardt,  D.,   Virch.  Arch.,  Bd.  127,  p.  85. 

Virchow,  R.,  Virch.  Arch.,  Bd.  v,  p.  363. 

Hartung,  O.,  Deutsche  Med.  Woch.,  No.  38,  p.  847,  1890. 

Langerhans,  Virch.  Arch.,  Bd.  124,  p.  373. 

Schmidt,  Adolf,  "  Untersuch.  iiber  menschl.  Magenepithel,  normal  u. 
pathol.,"   Virch.  Arch.,  Bd.  143,  xix. 

Cohnheim,  Paul,  "Die  bedeut.  klein.  Schleimhaut-Stiickchen  f.  d.  Diagnose 
d.  Magenkrankh.,"  Archiv  f.   Verdauungskrankh.,  Bd.  I,  S.  274. 


CHAPTER  XIV. 

THE   DIAGNOSTIC  SIGNIFICANCE   OF  FRAGMENTS  OF 
GASTRIC    MUCOSA. 

One  of  the  first  to  utilize  these  fragments  for  diagnostic  purposes 
was  Boas,  who  attributed  great  importance  to  this  way  of  finding 
out  the  real  state  of  the  mucosa.  He  held  that  in  certain  condi- 
tions of  suppressed  secretion  the  differential  diagnosis  between  a 
possible  neurosis  and  a  genuine  gastritis  with  glandular  atrophy  was 
only  possible  by  examination  of  such  pieces  of  mucosa.  Rosen- 
heim [loc.  cit.),  Boas  [loc.  cit.),  and  Julius  Friedenwald  {Medical  Nezvs, 
June  22,  1895),  emphasize  the  value  of  qualitative  and  quantitative 
testing  of  rennin  zymogen  to  differentiate  between  chronic  gastritis 
with  glandular  atrophy  and  carcinoma  on  the  one  hand,  and 
nervous  dyspepsia  and  secondary  gastritis  on  the  other.  However, 
Ewald  {loc.  cit.),  and  also  Einhorn  {loc.  cit.),  have  asserted  that 
absolute  deficiency  of  rennin  zymogen  is  not  pathognomonic  of 
atrophy,  therefore  it  would  indeed  seem  as  if  a  certain  diagnosis 
could  only  be  made  by  a  small  piece  of  mucosa. 

Is  there  any  clue  which  can  be  derived  from  these  pieces  regard- 
ing the  state  of  the  mucosa  in  the  secretory  disorders  ?  This  we 
will  try  to  answer  in  the  following.  Hayem,  to  whom  we  are 
indebted  for  the  best  histological  investigations  of  the  gastric 
mucosa,  emphasizes  that  the  individual  elements  of  the  mucosa, 
gland-ducts,  superficial  epithelium,  and  interstitial  tissue  can  become 
diseased  in  a  variety  of  ways  ;  the  various  portions  of  the  stomach 
fundus,  pylorus,  and  cardia  may  exhibit  different  affections  ;  and, 
finally,  the  mucosa  may  at  different  parts  show  different  phases  of 
disease.  He  distinguishes  a  parenchymatous  and  an  interstitial 
gastritis.     First,  the  parenchymatous: 

I.  Gastrite  parenchymateuse  hyperpeptique  chloro-organique. 
Under  this  he  has  two  sub-classes  :  {a)  D'emblee — dyspeptic  dis- 
tress coming  on  at  once — in  the  first  stage  of  digestion,  {b) 
Tardive — dyspeptic  distress  coming  on  in  later  stages — in  one  and 
one-half  to  two  hours.     Under  this  hyperpeptic  parenchymatous 

129 


130  CHANGES    IX    THE    GLAND-CELLS. 

gastritis,  Hayem  means,  clinically,  a  hyperpepsia  with  hyperacidity 
and,  anatomically,  degeneration  of  the  principal  central  or  chief 
cells,  with  proliferation  of  the  parietal  border  or  oxyntic  cells. 

2.  Gastrite  parenchymateuse  muqueuse  (gastritis  mucipara),  by 
which  he  means  a  mucous  degeneration,  a  process  taking  place 
principally  in  the   vestibules  to  the  gland-ducts  (which  are   lined 

•    .  (  V.e       ^  ^      /y^ 


J     .  -^       -*   •    .  '    ^  .  • 


.' 

V   ? 

~^   ,/ 

» 

K  '. 

,  ^        •" 

«  1     "^ 

• 

u. 


^ 

* 


3 


)  ^ 


/ 


A 


'/^* 


/ 


Fig.  20. — Fragment  of  Mucosa  showing  a  Normal  Condition  op  Glands:  very  slight  round-celled 
infiltration.     The  piece  became  detached  above  the  level  at  which  the  oxyntic  celLs  are  found.     X  600. 

with  columnar  epithelium)  and  corresponds  to  the  Schleimkatarrh 
of  most  German  writers.  This  is  associated  with  hypopepsia  and 
subacidity. 

3.  Gastrite  parenchymateuse  atrophique,  which  signifies,  anatom- 
ically, the  total  atrophy  of  the  glands  without  interstitial  pro- 
cesses, and,  clinically,  anacidity  or  achylia.  The  interstitial  forms 
he  separates  into  two  classes  : 


CHANGES    IN    THE    INTERSTITIAL    TISSUE. 


131 


(a)  Those  in  which  the  round-cell  infiltration  ; 

(d)  Those  in  which  the  sclerosis,  /.  e.,  connective-tissue  prolifera- 
tion, predominates. 

These  processes  are  described  as  occurring  purely  as  such, 
or  mixed  with  forms  of  parenchymatous  gastritis,  and  as  leading 
to  sub-  or  anacidity.  In  order  to  bring  our  results  in  critical  con- 
sideration with  those  of  Einhorn  (/oc.  cit.),  we  have  adopted   his 


Fig.  21. — Hypertrophy  and  Proliferation  of  Glandular  Elements. — {^From  a  case  of  persist- 
e7it  hyperacidity  found  in  the  eye  of  the  tubers    X  500. 


classification  of  the  anatomical  conditions  found  in  these  frag- 
ments. There  is,  however,  one  objection  that  can  be  urged  against 
it,  and  that  is  the  apparent  fact  that  he  has  based  his  system 
upon  conditions  of  the  gland-tubes  and  interglandular  tissue 
exclusively,  and  mentions  the  state  of  the  cells  only  once  in  six 
types  described.     We  will  therefore  supplement  his  categories  by 


132  TYPES    OF    ABNORMAL    CHANGES    IN 

adding  the  state  and  condition  of  the  vestibular  or  alveolar  colum- 
nar cells  (Vorraumzellen),  and  the  condition  and  numerical  rela- 
tions of  the  chief  central  or  ferment  cells  (Hauptzellen),  and  the 
parietal,  border,  or  oxyntic  cells  (Belegzellen). 

1.  Nonnal. — The  gland-ducts  and  interglandular  tissue  exist  in 
normal  proportions.  The  columnar  epithelium  of  the  surface  and 
of  vestibule  is  normal,  with  scattered  cells  showing  at  their  free  ends 
slight  mucoid  metamorphosis.  Average  number  of  parietal  or 
oxyntic  cells  in  six  ducts  which  were  sectioned  very  nearly  down  the 
center  =  22-40.     (Fig.  20.) 

2.  Cojincctive-iissue  Excess. — Proliferation  of  connective  tissue 
around  the  glands — glands  and  epithelial  cells  as  in  normal 
condition. 

3.  Proliferation  of  Glands. — Under  this  class  we  have  in  19  cases 
been  impressed  with  the  probability  that  there  must  be  three  types 
of  this  condition. 

Type  a — In  this  subtype  there  is  a  proliferation  of  gland-tubules. 
Under  the  same  field  of  microscope  there  wall  be  more  than  under 
normal  conditions,  since  they  are  much  closer  to  each  other,  but 
the  number  of  central  and  oxyntic  cells  are  from  18-42,  or  the 
same  as  under  the  normal  condition. 

Type  /' — Increase  of  oxyntic  or  parietal  cells  with  normal  number 
of  gland  ducts.  Here  there  seems  to  be  no  proliferation  of  the 
eland-ducts.  The  connective  tissue  and  the  ducts  bear  the  same 
relation  as  in  class  i,  but  the  anilin-staining  oxyntic  cells  may  be 
so  increased  that  they  lie  in  juxtaposition,  giving  the  whole  duct 
the  appearance  of  a  peptic  duct  of  the  dog  ;  the  number  may  reach 
70  in  one  duct.     The  oxyntic  cells  are  increased  in  size. 

Type  c — Increase  of  the  number  of  ducts  in  which  the  number 
of  oxyntic  cells  appear  normal  in  size  and  number,  and,  in  the  same 
fragment  or  section,  portions  of  mucosa  in  which  the  ducts  are  not 
augmented  but  the  oxyntic  cells  are  increased  in  number  and  size  ', 
this  third  type  is  a  combination  of  types  a  and  b.  When  there  are 
many  oxyntic  cells  above  the  normal  the  entire  gland  duct  assumes 
a  tortuous  or  elongated  shape.  It  seldom  extends  down  into  the 
mucosa  in  the  same  plane,  therefore  it  is  very  rare  that  a  section 
will  strike  down  the  middle  of  a  duct.  Generally  the  counts  in 
six  ducts  struck  fairly  along  the  central  canaliculus  are  taken  as  an 
average. 

4.  Incipient  Atrophy. — To  the  same  field,  under  the  micrometer, 


THE  GLANDULAR  ELEMENTS. 


133 


there  are  fewer  glands  present  than  normally  ;  they  appear  shrunken 
and  smaller,  at  the  same  time  the  spaces  between  the  glands  are 
lareer  than  normal  owing  to  an  increased  connective-tissue  forma- 
tion  ;  the  latter  is  thickly  invaded,  as  a  rule,  with  small  round-cell 
infiltration.     The  next  type  is — 


Fig.  22. — Atrophy  and  Vacuolization  of  Glandular  Elements— Mucoid  Degeneration  of 
Peptic  Cells— Increase  of  Interstitial  Connective  Tissue — Small  Round-celled  Infil- 
tration.— {From  a  case  of  chronic  alcoholic  gastritis.    Found  in  the  -wash-water.)     X  5°^- 


5.  Atrophy. — In  complete  atrophy  there  are  only  remnants  of 
glands  left,  a  few  degenerated  cells  lying  in  empty  circular  spaces 
where  glands  had  previously  existed  ;  there  is  also  a  diffuse  round- 
celled  infiltration  (see  Fig.  22). 

6.  Vacuolization. — Round  or  ovoid  vacuoles  exist  within  the 
glands  in  large  numbers,  being  the  result  of  mucoid  degeneration 
of  some  of  the  glandular  cells ;  this  is  generally  associated  with 


134  RELATION    OF    GLANDULAR    CHANGES 

connective-tissue  proliferation  (see  Fig.  22).  Vacuoles  are  present 
in  the  gland-cells  normally,  as  can  be  seen  in  the  drawings  of  Kupher 
and  Stohr.  We  have  also  seen  them  in  both  longitudinal  and  cross- 
section  of  the  gland-tubules,  but  rarely  more  than  two  or  three  to 
the  entire  duct.  It  is  conceivable  that  they  may  be  produced  by 
the  process  of  hardening  and  imbedding.  Some  of  the  fragments 
obtained  from  stomachs  may  show  characteristics  of  two  types. 

Deductions  from  36  Cases. — In  eight  lieaWiy  persons,  the 
mucosa  fragments  were  normal  in  six;  proliferation  and  autodi- 
gestion  marked  in  one,  which  showed  also  beginning  small  round- 
cell  infiltration  between  the  ducts;  connective-tissue  increase  in 
one.  In  the  first  of  these  cases  the  examination  showed  prolifera- 
tion in  one  fragment,  and  a  normal  condition  in  a  second  found  in 
the  same  wash  water. 

In  18  cases  oi  hyperacidity  tX^^  fragments  of  gastric  mucosa  found 
were  apparently  normal  in  four. 

Atrophy  of  gland-tubules  and  connective-tissue  increase,  so  that 
there  were  fewer  glands, — but  in  these  few  there  were  contained  a 
larger  number  of  oxyntic  cells  than  normal, — in  two  cases. 

Proliferation  of  gland-ducts,  with  apparently  normal  oxyntic 
cells,  in  six  cases. 

Proliferation  of  oxyntic  cells,  generally  without  marked  increase 
in  the  gland-tubules,  in  six  cases. 

In  twelve  cases  of  anacidity  or  siibacidity,  the  fragment  was  ap- 
parently normal  in  two  cases. 

Proliferation  of  glands,  with  marked  small  round-cell  infiltration, 
was  found  once. 

Atrophy  in  some  form  was  found  in  the  fragments  from  the  nine 
remaining  cases. 

In  establishing  the  classification  of  euchlorhydria  and  hyperchlorhydria,  we 
could  not  be  guided  exclusively  by  the  amount  of  free  HCl  found  after  the 
double  test-meal. 

Thus,  a  young,  vigorous  farmer,  aged  25,  who  never  had  any  disease, 
showed  on  repeated  examination  an  amount  of  free  HCl  equal  to  60°,  with  a 
total  acidity  of  80°.  Ordinarily,  judging  simply  from  the  analysis,  such  a  case 
would  be  diagnosed  as  hyperacidity,  according  to  the  principles  defined  in 
the  chapter  on  the  normal  amount  of  HCl;  however,  these  cases  can  be 
diagnosed  justly  and  accurately  when  considered  together  with  concomitant 
signs  and  symptoms  only.  Although  this  case  had  the  large  amount  of  free 
HCl,  there  was  no  starch  indigestion,  no  erythrodextrin,  no  pyrosis  ;  there  were 
no  symptoms  referable  to  the  stomach  at  all ;  the  man  was  in  perfect  health. 


Hyperacidity  in  i8  cases, 


TO    SECRETORY    DISORDERS.  135 

Another  case,  a  neurasthenic  female,  had  intense  suffering  from  hyper- 
acidity and  occasional  gastroxynsis,  and  the  amount  of  free  HCI  was  never 
over  40°.  This  case  showed  hypermotility ;  the  stomach,  as  a  rule,  was  empty 
twenty-five  minutes  after  an  Ewald  test-meal ;  with  our  intragastric  rubber  bag, 
in  connection  with  the  kymograph,  she  showed  very  frequent  and  sudden 
gastric  peristalsis  of  unusual  tonicity. 

Summary  of  results  from  examination  of  fragments  of  mucosa: 

r  Perfectly  normal  in  six. 

„.,,,,  \    (a)  Glandular  proliferations,  (l>)  Normal  in  one  (same 

tight  healthy  persons,    ■    ^    ^  \ 

°  ■'  ^  '  person). 

L  Connective-tissue  increase  in  one. 

Normal  in  four. 

Atrophy  in  two. 

Proliferation  of  glands  in  six. 

Proliferation  or  hypertrophy  of  oxyntic  cells  in  six. 

r  Normal  in  two. 
Anacidity  or  Subacidity,  .    ■{    Proliferation  of  glands  in  one. 
L  Atrophy  in  nine. 

Proliferation,  therefore,  according  to  this  table,  is  present  in  two- 
thirds  of  these  cases  of  hyperacidity,  and  atrophy  in  three-quarters 
of  these  cases  of  anacidity  or  subacidity.  Einhorn  (/oc.  cit.)  does 
not  give  any  results  from  examination  of  perfectly  healthy  indi- 
viduals, as  his  cases  of  euchlorhydria  seem  to  be  in  patients. 

Of  the  12  hyperacid  cases,  three  were  normal,  or  very  nearly  so, 
six  showed  proliferation,  and  three  showed  connective-tissue  pro- 
liferation. In  his  cases  of  anacidity,  or,  rather,  what  he  calls  achylia 
gastrica,  of  which  there  were  seven  cases,  there  was  atrophy  three 
times,  marked  vacuolization  once,  proliferation  once,  and  normal 
condition  twice. 

On  the  whole,  judging  from  Einhorn's  results,  Cohnheim's, 
Hayem's,  and  our  own,  the  conclusions  seem  justifiable  that  pro- 
liferation of  glandular  elements  is  present  in  from  one-half  to  two- 
thirds  of  the  cases  of  hyperacidity ;  and  atrophy  is  present  in  from 
one-half  to  two-thirds  of  the  cases  of  anacidity. 

Adolph  Schmidt  {Virdiow' s  Archiv,  Bd.  cxliii,  S.  478)  asserts 
that  the  epithelium  of  the  surface  of  the  stomach  is  preserved 
better  than  the  gland-cells  in  inflammatory  conditions  of  the 
mucosa.  This,  he  says,  is  particularly  so  in  chronic  gastritis, 
which  forms  island-like  foci  in  stomachs  otherwise  not  much 
changed.  Our  experience,  and  that  of  W.  D.  Booker,  is  not  in 
accordance  with  this  observation  (see  pathology  of  simple,  acute, 
and  chronic  gastritis  in  the  clinical  portion  of  this  work).    Although 


136  FRAGMENTS    OF    NEOPLASMS. 

we  preserved  the  stomachs  by  injecting  them  immediately  after 
death  (within  twenty  minutes)  with  alcohol,  also  with  formalin 
and  sublimate,  so  that  autodigestion  was  at  once  checked,  our  sec- 
tions showed  generally  a  more  serious  destruction  of  the  surface 
epithelium  than  of  the  gland-cells.  At  times  both  are  so  much 
altered  that  it  is  impossible  to  say  which  is  most  or  least  affected. 
It  seems  in  chronic  gastritis  that  new  epithelium  will  be  re-formed 
quite  rapidly  where  the  old  has  been  lost  or  destroyed. 

In  cases  of  suspected  malignant  neoplasm,  fragments  of  the 
growth  are  occasionally  found  and  are  of  importance  in  the  diag- 
nosis. In  carcinoma  of  the  cardia  or  the  esophagus,  they  are 
most  frequently  found  in  the  lower  or  side  opening  of  the  tube,  as 
it  must  pass  through  or  over  the  growth  on  its  way  into  the 
stomach.  But  even  in  malignant  growths  of  other  parts  of  the 
stomach,  patient  searching  in  the  sediment  of  the  washwater  will 
sometimes  reward  the  clinician  by  the  discovery  of  tumor  frag- 
ments. Of  the  first  washwater  in  the  morning,  about  500  c.c.  should 
be  permitted  to  settle  twelve  hours  in  a  conical  glass  such  as  is 
used  for  the  settling  of  solid  urinary  constituents,  or  the  gastric 
contents  should  be  brought  to  settle  out  minute  particles  by  use  of 
the  centrifuge.  The  sediment  should  be  examined  under  a  low 
power  (about  50  diam.).  The  centrifuge  is  preferable,  as  long 
standing  of  the  fluid  causes  putrefaction. 

Once  we  made  the  diagnosis  of  carcinoma  when  no  tumor  was 
evident,  from  repeatedly  finding  involuntary  muscle-fibers  when 
no  meat  had  been  eaten  for  six  days  after  thorough  lavage.  It 
proved  to  be  a  broad,  flat  carcinoma  of  the  posterior  wall.  The 
method  of  recognition  of  neoplastic  fragments  will  be  fully  con- 
sidered in  the  chapter  on  Carcinoma. 

The  drawing  of  a  longitudinal  section  of  the  secreting  gland- 
tubules,  showing  beautifully  the  well-preserved  cylindrical  epithe- 
lium of  the  gastric  surface  and  well-differentiated  oxyntic  and 
chief  cells,  was  made  from  several  sections  of  a  piece  of  mucosa  that 
was  torn  loose  by  the  stomach-tube,  inserted  by  a  medical  student, 
who  tried  to  aspirate  by  means  of  the  pump  a  meal  that  had 
disagreed  with  him.  The  tearing  off  must  have  occurred  in  an 
instant,  as  there  were  no  signs  of  inflammation  in  the  sections. 
The  sections  were  stained  in  a  variety  of  ways,  principally  in  the 
eosin,  hematoxylin,  Golgi,  and  Bismarck  -  brown  stains.  The 
minute  communications  of  the  oxyntic  or  parietal  cells  with  the 


VARIATIONS    IN    STATE    OF    GLANDS.  1 3/ 

central  duct  are  best  brought  out  by  the  Golgi  method  (see 
frontispiece). 

The  drawings  of  fragments  found  in  the  washwater,  illustrating 
glandular  proliferation,  with  glands  closely  packed  and  connective 
tissue  diminished  and  of  glandular  atrophy,  mucoid  degeneration, 
vacuolization,  and  small-cell  infiltration,  are  all  explained  by  the 
text  accompanying  the  illustrations.  We  have  seen  that  histologi- 
cal changes  approaching  or  actually  representing  pathological 
states  may  be  going  on  in  perfectly  healthy  stomachs.  Further- 
more, the  stomachs  of  diseased  patients  may,  on  serial  sections, 
show  a  different  pathological  state  at  different  places  of  the  mucosa. 
Therefore  it  must  be  borne  in  mind,  that  although  the  findings  in 
hyperacidity  and  anacidity  appear  to  be  in  some  relation  to  the 
disease,  this  kind  of  investigation  must  not  be  relied  upon  as 
representing  in  a  given  fragment  the  condition  of  the  entire 
mucosa.  It .  represents  the  state  of  the  location  whence  it 
sequestrated  ;  that  location  not  being  accurately  known,  general- 
izations must  be  made  with  caution. 

It  should  be  emphasized  that  the  most  important  conditions  in 
these  fragments  are  not  the  number  of  gland-ducts  and  the  state 
of  the  connective  tissue,  but  the  relative  number  of  oxyntic  or 
border  and  chief  or  central  cells.  A  fragment  may  show  a  normal 
or  subnormal  number  of  gland-ducts,  and  at  the  same  time  these 
may  contain  an  abnormally  large  number  of  cells. 


CHAPTER  XV. 

OCCURRENCE   OF   SECRETIONS   IN   THE   EMPTY 
STOMACH. 

Stimulations  to  Secretions  of  Gastric  Juice. — Significance  of  Foam. — 

Preparation  of   Gastric    Contents. — Quantitative   Analysis. 

— Methods. — Standard  or   Normal  Solutions. — 

Indicators. —  Titration. — Apparatus.  * 

Most  authors  are  of  the  opinion  that  no  secretion  is  con- 
tained in  the  empty  stomach.  Schreiber  {Aixh.  f.  exper.  Pathol, 
u.  Pilar.,  Bd.  xxiv,  S.  365  ;  also,  Deutsche  ined.  Wocliensclir.,  1 894, 
Nos.  18  to  21),  however,  concludes  that  a  secretion  is  found  also  in 
the  empty  stomach ;  that  is,  he  denies  a  continuous  secretion  or 
gastrosuccorrhea  as  a  disease  sui  generis,  and  claims  to  be  able  to 
obtain  60  c.c.  of  a  secretion  possessing  good  digestive  power  from 
a  jejune,  or  fasting,  stomach. 

Pick  {Prager  med.  Wochenschr.,  1889,  No.  18),  who  obtained  similar 
results,  believed  that  the  secretion  was  set  up  by  the  stimulation  of 
the  sound  used.  .  Rosin  [Deutsche  med.  Wochenschr.,  1888,  No.  47), 
A.  Hoffmann  [Berlin,  klin.  Wocliensclir.,  1889,  No.  12),' and  Martins 
[Deutsche  med.  Wochenschr.,  1894,  p.  638),  have  also  obtained  a 
digestive  secretion  from  the  fasting  stomach. 

Although  there  may  be  found  50  to  60  c.c.  of  a  secretion  possess- 
ing digestive  powers  in  the  empty,  normal  stomachs  of  perfectly 
healthy  individuals,  this  does  not  prove  that  a  continued  secretion 
exists  normally  (Riegel,  Deutsche  vied.  Wochenschr.,  1893,  p.  735). 
Leo  ("  Krankheiten  d.  Bauchorgane,"  p.  54)  considers  this  digestive 
secretion  a  residuum  of  the  last  previous  meal,  and  seems  to  have 
shown  conclusively  that  such  a  residuum  is  constantly  present  in 

*  The  section  on  quantitative  chemical  analysis  of  gastric  contents  and  the  chapters  on 
the  condition  of  the  blood  and  urine  in  gastric  diseases  and  on  the  gases  of  the  stomach 
have  been  written  by  my  associate,  Dr.  Edward  L.  Whitney,  whose  experience  as  demon- 
strator of  clinical  pathology  has  admirably  fitted  him  for  the  concise  and  clear  account 
of  this  department.  It  gives  me  pleasure  to  express  my  thanks  to  him  for  his  assistance. 
-(J.  C.  H.) 


GASTRIC    SECRETION    IN    THE    EMPTY    STOMACH.  1 39 

the  Stomachs  of  infants  after  a  night's  sleep  (see  Leo,  Berlin,  kliji. 
Woclujischr.,  1888,  No.  49).  For  the  practical  objects  of  diagnosis 
he  concludes  that  a  secretion  of  50  to  60  c.c.  of  digestive  fluid  found 
in  a  fasting  organ  must  not  be  considered  pathological.  Only  when 
the  amount  gained  reaches  100  to  300  c.c.  does  it  indicate  hyper- 
secretion, which  is  often  associated  with  hyperacidity  (Reichmann, 
Berlin,  klin.  Wochenschr.,  1887,  S.  12  ;  Bouveret  \loc.  cit7\  ;  Debove, 
and  Remond,  "  Les  Maladies  de  I'Estomac").  Riegel  and  Reich- 
mann do  not  distinguish  sufficiently  between  so-called  continuous 
secretion  of  gastric  juice  with  a  stomach  of  normal  capacity  and 
normal  exit  to  the  duodenum  and  continuous  secretion  which 
appears  as  a  concomitant  symptom  of  gastrectasia  with  probable 
pyloric  stenosis.  Einhorn  asserts  that,  with  more  accurate  differ- 
entiation between  these  states,  it  will  probably  be  found  that  the 
normal  stomach  in  a  fasting  condition  contains  very  little  if  any 
secretion.  We  have  seen  a  number  of  cases  whose  stomachs  were 
of  natural  size  and  where  there  was  no  disturbance,  but  which  con- 
tained this  secretion  early  in  the  morning  before  breakfast. 

J.  Schreiber  {Deutsche  med.  Wochenschr.,  1894,  No.  53)  has  experi- 
mented upon  two  healthy  persons,  before  any  food  had  been  taken, 
and  found  gastric  juice  with  hydrochloric  acid  in  both.  The  amount 
of  secretion  thus  obtained  varied  from  10  to  22  c.c.  Martius 
{Deutsche  vied.  Wochensclir.,  1894,  No.  32)  and  Huber  {Korrespon- 
denzblait  f.  Schweizer  Aerzte,  1894,  No.  49)  confirm  Schreiber's 
results.  According  to  Ewald,  who  sums  up  the  literature  (in 
Lubarsch  and  Ostertag's  "Ergebnisse  d.  spez.  Pathologic,"  Bd.  iii, 
S.  27),  and  gives,  his  own  observations  in  a  large  number  of  cases, 
this  problem  is  represented  in  the  following  manner  :  In  many  indi- 
viduals small  quantities  of  a  digestive  secretion  containing  free  hydro- 
chloric acid  can  be  obtained  from  the  fasting,  or  jejune,  stomach. 
Sometimes  it  is  mixed  with  bile,  coloring  matter,  and  duodenal 
contents.  But  he  claims  that  the  stimulation  to  this  secretion  has 
been  furnished  by  swallowed  saliva  (Martius),  remnants  of  food, 
pharyngeal  secretion,  etc.,  and  that  the  state  of  things  lies  between 
a  normal  and  an  abnormal  one,  and  that  there  is  no  diseased  con- 
dition of  the  gastric  mucosa. 

In  the  case  of  typical  gastrosuccorrhea,  however,  there  is  a  much 
increased  irritability  of  the  mucosa,  giving  rise  eventually  to  a 
profuse  secretion,  which,  when  found  in  empty  stomachs,  is  quan- 
titatively  more    considerable    than    that    found    in    normal  jejune 


140  MEANS    OF    OBTAINING    GASTRIC    SECRETION. 

stomachs.  Huber  compares  it  to  a  slow,  gradual  dying  away  of  the 
tonus  of  secretory  irritability  ("Abklingen  des  Sekretionsreizes") 
that  has  been  set  up  by  the  ingesta  and  seems  to  linger  after  they 
have  passed  into  the  duodenum. 

In  order  to  obtain  gastric  secretion  a  variety  of  methods  have 
been  suggested : 

By  chemical  stimulation,  according  to  Leube's  method,  which 
consists  in  allowing  50  c.c.  of  a  three  percent,  solution  of  sodium 
bicarbonate  to  flow  into  the  stomach.  After  twelve  minutes  this  is 
washed  out  again,  and  should  be  found  neutral.  By  thermic  stimu- 
lation, according  to  Jaworski's  method,  consisting  of  the  introduc- 
tion of  100  c.c.  of  ice-water  and  washing  it  out  again  after  ten 
minutes,  when  it  should  contain  acid  and  pepsin.  These  methods, 
if  successful  at  all,  bring  out  the  gastric  juice  in  a  most  diluted 
state,  and  therefore  give  no  adequate  means  of  determining  the 
secretion  by  chemical  analysis.  It  has  been  claimed  by  Einhorn 
{New  York  Medical  Record,  November  9,  1889)  and  Allen  A.  Jones 
{ibid.,  1 891)  in  this  country,  and  Hoffmann  {Berlin,  klin.  Wochenschr., 
1889,  No.  13),  Ewald  {loc.  cit.),  and  Ziemssen  in  Germany,  that  the 
gastric  secretion,  as  evinced  by  the  amount  of  hydrochloric  acid, 
could  be  increased  by  faradic  or  galvanic  stimulation.  While  we 
have  our  doubts  about  this  matter,  we  do  not  wish  to  imply  that 
electricity  is  not  a  very  valuable  therapeutic  agent  in  the  treatment 
of  secretory  diseases  ;  we  could  not,  in  fact,  dispense  with  it  as  an 
auxiliary  to  treatment.  In  our  opinion,  the  influence  of  electricity 
on  secretion  is  still  doubtful. 

As  a  means  of  obtaining  gastric  secretion,  this  method  is  certainly 
not  available.  The  normal  secretions  are  best  obtained  by  the 
natural  stimulation  of  one  of  the  test-meals  as  stated  in  a  previous 
chapter. 

Mathieu  and  Remond  {Societe  de  Biolog.,  1890)  have  published  a 
method  of  determining  the  total  quantity  of  stomach  contents  by 
finding  out  the  acidity  of  the  undiluted  contents  as  much  as  can  be 
drawn ;  then  that  of  the  contents  as  much  as  can  be  gained  by 
washing  out  the  stomach  with  a  known  quantity  of  water,  and  from 
this  the  acidity  of  the  total  amount  of  contents  that  were  originally 
in  the  stomach  are  calculated.  Strauss  {Therapcutische  Monatshefte , 
Marz,  1895)  has  simplified  this  procedure,  but  for  the  practitioner 
it  is  sufficient  to  know  the  amount  gained  by  the  simple  methods 
of  drawing  the  contents  by  expression  or  aspiration.     Concerning 


PREPARATION    OF    GASTRIC    CONTENTS.  I4I 

the  recognition  of  proteid  and  carbohydrate  indigestion  from  the 
food-remnants,  it  should  be  added  this  is  much  facilitated  by  the 
double  test-meal  used  at  our  hospital  (Maryland  General  Hospital). 

In  gastrectasias,  presence  of  foam  indicates  gas-fermentation. 
Gas  may  be  found  even  in  presence  of  normal  or  supernormal 
amount  of  hydrochloric  acid,  since  F.  Kuhn  [ZeitscJir.  f.  klin.  Med., 
Bd.  XXI,  and  Deutsche  med.  Wocheiischr.,  '92,  No.  49)  has  demon- 
strated that  the  hydrochloric  acid  of  gastric  juice  has  no  detrimental 
effect  on  large  amounts  of  yeast.  Whenever  there  is  stagnation 
of  gastric  contents  this  gas-formation  can  occur. 

After  the  contents  of  the  stomach  are  withdrawn,  they  must  be 
prepared  for  and  submitted  to  chemical  examination.  The  contents 
may  be  beaten  up  thoroughly  to  make  a  homogeneous  mixture, 
and  the  chemical  examinations  conducted  on  this  mixture,  or  this 
mixture  may  be  filtered  and  the  clear  filtrate  subjected  to  analysis. 
The  former  method  gives  the  more  accurate  results,  with  slightly 
higher  acidity,  than  the  latter  method,  which  has  the  advantage, 
however,  of  allowing  better  observation  of  color  changes  in  the 
solution  during  titration. 

Before  entering  upon  a  discussion  of  the  chemical  methods  as 
applied  to  the  gastric  juice,  a  short  description  of  the  methods, 
solutions,  and  apparatus  required  in  quantitative  analysis  will  be 
given. 

The  solutions  required  can  be  made  up,  and,  if  preserved  from 
the  influence  of  light  and  air,  can  be  kept  indefinitely. 

The  methods  used  in  quantitative  chemical  analysis  may  be 
divided  into  two  general  classes  :  Gravimetric  and  Vobinietric.  The 
gravimetric  methods  consist  of  the  isolation  of  the  substance  or 
one  of  its  compounds,  which  is  weighed.  The  isolation  of  sub- 
stances in  a  pure  state  often  requires  long  training  in  chemical 
methods,  and  if  a  small  amount  of  the  substance  in  question  is 
present  it  may  be  very  difficult  to  separate  a  weighable  amount 
unless  large  quantities  of  the  mixture  are  available.  Many  sub- 
stances can  not  be  separated  from  mixtures  without  losing  at  the 
same  time  their  relation  to  other  substances  in  the  same  solution. 
The  great  objection  to  the  gravimetric  method,  however,  is  the  large 
amount  of  costly  apparatus  necessary,  and  the  length  of  time 
needed  for  the  manipulations. 

The  volumetric  methods  are  more  easily  performed ;  in  this,  the 
quantity  of  the   substance   under  examination  is  ascertained  by  a 


142  STANDARD    SOLUTIONS. 

calculation  based  upon  a  measured  quantity  of  a  solution  of  a 
known  strength  required  to  perform  a  certain  reaction  with  it. 
These  solutions,  called  standard  solutions,  are  of  two  kinds,  normal 
solutions  and  empirical  solutions. 

A  normal  solution  is  one  which  contains  in  a  liter  a  quantity  of 
the  activ^e  reagent  expressed  in  grammes  and  chemically  equiva- 
lent to  one  atom  of  hydrogen.  In  other  words,  a  normal  solu- 
tion contains  in  looo  c.c.  an  amount  of  the  active  constituent  just 
sufficient  to  combine  with  or  replace  one  gramme  of  hydrogen. 

Decinormal  solutions,  Ni,,,  are  one-tenth  the  strength  of  normal 
solutions. 

Centinormal  solutions,  Nmo,  are  one-hundredth  the  strength  of 
nc/rmal  solutions. 

Empirical  solutions  are  those  which  do  not  contain  an  exact 
atomic  proportion  of  the  reagent,  but  are  made  up  of  such  strength 
that  one  c.c.  is  equivalent  to  some  definite  weight  of  the  substance 
sought. 

Residual  titration,  or  back  titration,  consists  in  treating  the  sub- 
stance under  examination  with  standard  solution  in  excess  of  that 
known  to  be  required  ;  the  excess  is  then  ascertained  by  residual 
titration  with  another  standard  solution. 

In  general,  titration  results  in  the  formation  of  a  compound  that 
can  be  distinguished  by  its  properties  from  those  substances  present 
in  either  solution. 

1.  It  may  form  a  precipitate. 

2.  It  may  cause  the  complete  solution  of  some  precipitate. 

3.  A  slight  excess  of  either  reagent  may  produce  some  visible 
change  in  some  constituent  of  the  solution,  or  a  change  in  some 
substance  added  for  the  purpose  (indicators). 

4.  The  indicator  in  some  cases  can  not  be  added  to  the  solution, 
but  from  time  to  time  a  few  drops  of  the  solution  are  added  to  the 
indicator  on  a  watch-glass  at  the  side. 

Of  the  above  the  normal  solution  is  the  most  used,  the  empirical 
solution  being  only  of  limited  application. 

It  would  seem  a  simple  matter  to  make  up  a  standard  solution 
which  would  be  perfectly  accurate,  but  in  practice  the  problem  is 
not  so  simple.  Absolutely  pure  chemicals  are  not  easily  obtained, 
and  such  as  are  easily  obtained,  unmixed  with  other  mineral  sub- 
stances, contain  a  variable  amount  of  water,  and  are,  moreover, 
exposed  to  more  or  less  danger  of  contamination  from  the  impuri- 


DECINOKMAL    SOLUTIONS.  I43 

ties  of  the  air.  The  following  methods  of  obtaining  a  tenth-normal 
solution  are  recommended  as  a  basis  for  the  preparation  of  other 
solutions. 

I.  Pure,  dry  oxalic  acid  is  obtained,  and  the  crystals  that  show  no 
sign  of  efflorescence  selected.  From  the  formula,  C2H2O4  -f  2H2O, 
it  is  seen  that  the  molecular  weight  is  126,  and  as  it  is  a  dibasic 
acid  the  normal  solution  would  contain  one-half  of  this  (63  gm.) 
dissolved  in  distilled  water  and  made  up  to  one  liter  at  a  temper- 
ature of  15°  C.  As  a  tenth-normal,  Njq,  solution  is  required,  one- 
tenth  of  this,  or  6.3  gm.,  are  made  up  to  a  liter  as  before,  and  used  to 
correct  the  solutions  employed  in  analysis.  It  must  be  noticed 
that  oxalic  acid  in  dilute  solution  soon  decomposes,  so  that  it  must 
be  freshly  prepared  as  required. 

To  prepare  an  equivalent  solution  of  caustic  soda  (decinormal 
NaOH)  about  five  gm.  of  caustic  soda  are  dissolved  in  about  900  c.c. 
of  distilled  water  and  well  mixed.  To  this  there  is  added  lime- 
water  or  baryta  water  Ca(OH)2  or  Ba(OH)2  as  long  as  a  precipi- 
tate forms,  to  get  rid  of  carbonates  or  sulphates.  The  solution  is 
allowed  to  stand  until  the  impurities  have  settled.  Twenty-five 
c.c.  of  the  solution  are  then  measured  with  a  pipette  into  a  clean 
flask  or  beaker  and  titrated  with  the  above  solution  of.  oxalic  acid, 
using  a  few  drops  of  phenolphthalein  as  an  indicator,  until  the  red 
color  of  the  solution  just  disappears.  The  solution  is  then  diluted 
to  the  strength  of  a  decinormal  solution. 

As  an  illustration  of  the  method  of  ascertaining  the  amount  of 
dilution  necessary  to  make  the  two  solutions  exactly  equivalent,  we 
will  suppose  that  the  25  c.c.  of  caustic  soda  solution  required 
28.3  c.c.  of  the  oxalic  acid  solution  to  discharge  the  red  color.  If 
25  c.c.  of  the  caustic  soda  solution  neutralize  28.3  c.c.  of  the  acid 
solution,  then  the  amount  of  caustic  soda  solution  necessary  to 
neutralize  lOOO  c.c.  of  the  acid  solution  will  be  found  by  the  fol- 
lowing proportion  : 

28.3:  25 :  :  1000:  (X)  X  =  883.4 

X^  amount  of  caustic  soda  solution  necessary  for  lOOO  Nu, 
NaOH.  Dilute  883.4  c.c.  of  the  caustic  soda  to  lOOO  c.c.  with  dis- 
tilled water. 

After  diluting  the  solution,  it  should  be  again  titrated  to  ensure 
its  accuracy,  and  if  properly  standardized  it  should  be  changed  from 
red  to  colorless  and  vice  versa  by  the  addition  of  a  drop  or  two  of 


144  INDICATORS. 

the  acid  or  alkaline  solutions,  respectively.  The  titration  should  be 
conducted  as  rapidly  as  possible  to  avoid  the  error  produced  by 
absorption  of  CO2  from  the  air,  and  all  solutions  kept  in  well-stop- 
pered bottles  for  the  same  reason. 

2.  About  eight  gm.  of  pure,  dry  sodium  carbonate  are  heated 
in  a  platinum  crucible  for  ten  minutes  at  a  dull-red  heat,  stirring 
occasionally  with  a  platinum  wire.  After  heating,  it  is  powdered  in 
a  warm  mortar  and  allowed  to  cool  in  a  desiccator.  When  cool,  5.3 
gm.  of  the  powder  are  weighed  rapidly,  washed  into  a  flask  with 
hot  distilled  water,  and  made  up  to  a  liter.  This  constitutes  a  deci- 
normal  solution  of  sodium  carbonate. 

A  decinormal  solution  of  sulphuric  acid  is  prepared  in  the  fol- 
lowing manner :  About  three  c.c.  of  the  pure,  strong  acid,  of  a 
specific  gravity  of  1.840,  is  made  up  to  about  900  c.c. 

The  approximate  solution  is  standardized  against  the  sodium 
carbonate  solution  prepared  as  above,  using  a  drop  or  two  of  a 
O- 1  per  cent,  solution  of  methyl-orange  as  an  indicator.  Twenty- 
five  c.c.  of  the  acid  solution  is  titrated  with  the  decinormal  sodium 
carbonate  until  the  red  color  shown  by  this  indicator  in  acid  solu- 
tion turns  to  a  light  yellow.  The  correction  of  the  approximate 
solution  is  made  from  a  proportion  upon  exactly  the  same  principle 
as  in  the  former  case  (No.  i). 

To  correct  this  decinormal  solution  of  sulphuric  acid  for  very 
accurate  work,  the  following  method  is  recommended:  One  hun- 
dred c.c.  of  the  decinormal  solution  of  sulphuric  acid  is  alkalinized 
with  a  strong  solution  of  pure  ammonia  (ammonium  hydrate).  The 
solution  is  evaporated  on  the  waterbath,  heated  to  105°  C.  in  hot- 
air  bath,  cooled,  and  weighed.  The  amount  of  sulphuric  acid  is 
calculated  from  the  amount  of  ammonium  sulphate  formed. 

Indicators. — An  indicator  is  a  substance  used  in  volumetric 
analysis,  which  indicates,  by  change  of  color  or  some  other  visible 
effect,  the  exact  point  at  which  a  given  reaction  is  complete. 

Generally  the  indicator  is  added  to  the  substance  under  examina- 
tion, but  in  a  few  cases  it  is  used  outside,  a  drop  of  the  solution 
being  brought  in  contact  with  a  drop  of  the  indicator. 

The  particular  uses  of  the  indicators  will  be  more  fully  explained 
in  their  proper  places,  under  the  quantitative  examination  of  the 
gastric  juice,  but  the  chief  ones  in  use  in  such  examinations  may  be 
briefly  mentioned. 

Tincture  of  litmus,  which  turns  red  in  acid  solution,  blue  in  an 


APPARATUS.  145 

alkaline  solution.     It  is  used  in  solution,  and  also  in  the  form  of 
test-papers.     (It  is  not  used  when  carbonates  are  present.) 

Phenolphthalein  solution,  a  one  per  cent,  solution  of  phenol- 
phthalein  in  alcohol,  colorless  in  acid  solutions,  red  in  alkaline 
solutions.  Is  not  reliable  for  alkaline  phosphates,  bicarbonates,  or 
ammonia. 

Methyl-orange  solution,  a  O.i  per  cent,  solution  of  methyl- 
orange  in  water,  turns  red  with  acids,  yellow  with  alkalies.  It  is 
not  affected  by  carbonic  acid,  and  is  valuable  for  titration  of  alkaline 
carbonates. 

The  other  indicators  and  their  uses  in  analysis  of  the  gastric 
juice  will  be  mentioned  later. 

Apparatus. — The  apparatus  needed  for  volumetric  Work  is  com- 
paratively simple, — burettes,  measuring-flasks,  measuring-cylinders, 
and  pipettes.  An  accurate  balance  is  required  in  all  chemical 
work,  delicate  to  a  milligramme  and  weighing  up  to  say  50 
gm.  Burettes  are  glass  tubes  graduated  to  tenths  of  a  c.c, 
and  holding  from  25  to  100  c.c.  They  are  provided  at  the  lower 
end  with  a  rubber  tube  and  pinch-cock,  by  means  of  which  the 
amount  of  the  solution  can  be  accurately  regulated.  The  tube  is 
graduated  upon  its  outer  surface,  and  the  amount  of  the  solution 
used  can  be  read  off  from  this  graduation.  The  simplest  form  of 
burette  is  the  one  already  described,  known  as  Mohr's,  of  which 
various  modifications  are  in  use. 

Measuring-flasks  are  vessels  made  of  thin  glass  having  a  narrow 
neck,  and  so  constructed  that  a  certain  amount  of  fluid  reaches  a 
graduation  placed  about  the  middle  of  the  neck.  These  flasks  are 
of  various  sizes, — 100,  200,  250,  500,  and   lOOO  c.c. 

Measuring-cylinders  are  of  various  sizes,  from  25  to  loooc.c. ; 
graduated  from  0.5  to  five  c.c. 

Pipettes  are  of  two  kinds, — those  graduated  for  one  quantity 
only,  and  those  graduated  on  the  stem  to  deliver  various  quantities. 
A  convenient  set  for  stomach-work  is  the  following :  two,  five,  ten, 
and  25  c.c. 

In  addition  to  the  above  apparatus,  one  should  be  supplied  with 
funnels,  crucibles,  beakers,  flasks,  test-tubes,  Bunsen  burners,  etc. 

All  apparatus  should  be  kept  scrupulously  clean,  rinsed  before 
and  after  using  with  distilled  water.  It  is  well  to  wash  the  inside 
of  any  measuring-apparatus  two  or  three  times  with  small  portions 
of  the  solution  for  which  it  is  to  be  used. 


146  USE    OF    BURETTES. 

Greasiness  interferes  very  much  with  accurate  reading.  It  may 
be  removed  by  dilute  alkaline  solution. 

The  burette  should  be  placed  perfectly  perpendicular,  and  firmly 
fastened.  Fill  by  a  funnel,  the  stem  resting  against  the  inner  sur- 
face of  the  burette  to  avoid  the  formation  of  bubbles.  Always  fill 
above  the  zero  mark ;  gently  tap  the  burette  until  the  bubbles  dis- 
appear should  they  be  formed.  Then  run  out  a  small  portion  (or 
down  to  the  zero  mark),  remembering  to  run  out  enough  to  remove 
all  air-bubbles  from  the  bottom  of  the  burette. 

In  reading  the  results,  always  read  from  the  bottom  of  the 
meniscus  formed  by  the  rising  of  the  outer  borders  of  the  liquid 
along  the  sides  of  the  burette. 


CHAPTER   XVI. 
CHEMICAL   EXAMINATION  OF  GASTRIC  JUICE. 

Tests    for   Presence    of  Free   Acids. —  Tests  for   Free    Hydrochloric 

Acid. — The  Dimethyl-Amido-Azo-BetizoL  Test. —  The  Resor- 

cin  Test. —  Combined  Hydrochloric  Acid. — Lactic 

Acid:  Formation,  Significance,  Detection. 

Reaction. — The  reaction  of  the  gastric  juice,  obtained  by  means 
of  the  stomach-tube  or  otherwise,  after  the  administration  of  a  test- 
meal,  is  always  acid  in  the  normal  individual.  The  reaction  is  best 
determined  by  dipping  into  the  juice  a  piece  of  very  delicate  blue 
litmus  paper.  In  juice  of  acid  reaction  the  paper  immediately 
turns  red.  Very  rarely  is  the  reaction  alkaline,  this  being  found 
only  in  a  few  cases  of  atrophy  of  the  gastric  mucosa,  occasionally 
in  acute  gastritis,  and  when,  for  some  reason,  a  portion  of  the 
intestinal  contents  and  the  alkaline  bile  has  been  forced  through 
the  pylorus  in  sufficient  quantity  to  neutralize  the  acid  of  the 
stomach. 

In  severe  cases  of  gastric  atrophy  the  reaction  is  usually  acid, 
even  in  absence  of  fermentative  changes.  This  is  due  to  the 
presence  of  acid  salts,  such  as  acid  sodium  phosphate  (NaHoPOi), 
and  of  traces  of  organic  acids,  which  occur  in  nearly  every  test- 
meal  in  quantities  sufficient  to  produce  an  acidity  of  from  six  to 
ten  degrees. 

Tests  for  Presence  of  Free  Acids. — A  delicate  test  for  the 
presence  of  free  acids  is  found  in  Congo-red.  This  substance 
occurs  as  a  fine  reddish-brown  powder,  dissolving  readily  in  water 
to  form  a  clear  deep-red  solution,  which  changes  in  the  presence 
of  free  acids  to  a  dark  blue.  It  may  be  used  in  two  ways  as  an 
indicator. 

I.  A  solution  is  prepared  by  dissolving  one  gm.  of  the  powder 
in  lOO  c.z.  of  water,  and  adding  a  drop  to  a  few  c.c.  of  the  gastric 
juice.     If  the  juice  contains  even  a  slight  trace  of  free  hydrochloric 

147 


148  TESTS    FOR    FREE    HCl. 

acid,  or  the  organic  acids  in  slightly  larger  quantities,  the  solution 
immediately  turns  a  bright  blue. 

2.  A  test-paper  may  be  prepared  by  soaking  bibulous  paper  in 
the  above  solution  of  the  dye  for  several  hours  and  then  carefully 
drying.  This  paper  is  simply  dipped  into  the  filtrate,  or  into  the 
contents  before  filtration,  and  exhibits  the  same  color  reaction  as 
the  solution  mentioned  above,  and  has  the  additional  advantages  of 
being  more  convenient  and  exhibiting  as  readily,  slight  changes  in 
color.  It  has  been  found,  also,  that  when  the  acidity  is  due  to 
organic  acids  and  not  to  free  hydrochloric  acid,  the  color  can  be 
made  to  disappear  by  warming  gently  over  the  open  flame.  If 
the  acidity  is  due  to  hydrochloric  acid,  on  the  contrary,  the  dark- 
blue  stain  on  the  paper  changes  to  a  lighter  tint,  but  does  not  dis- 
appear except  when  strongly  heated. 

It  must  be  emphasized  that  this  color-change  from  red  to  blue 
does  not  occur  in  solutions  of  acid  salts  or  in  the  presence  of  com- 
bined hydrochloric  acid,  and  therefore  indicates  the  presence  of 
some  free  acid, — inorganic  or  organic. 

Tests  for  Free  Hydrochloric  Acid. — Many  tests  have  been 
proposed  for  free  hydrochloric  acid,  the  following,  given  in  the  order 
of  their  accuracy  and  delicacy,  being  probably  the  most  reliable : 

1.  Dimethyl-amido-azo-benzol 0.02  pro  iocx3 

2.  Phloroglucin-vanillin, 0.05         " 

3.  Resorcin, 0.05         " 

The  Dimethyl-Amido-Azo-Benzol  Test. — This  test,  recently 
introduced  by  Topfer,  is  probably  destined  to  replace  all  others  in 
the  clinical  laboratory,  both  on  account  of  its  simplicity  and  also 
on  account  of  its  ready  application  to  the  direct  quantitative  esti- 
mation of  the  amount  of  free  hydrochloric  acid  in  the  gastric  juice. 
This  indicator  occurs  in  the  form  of  a  brown  powder,  readily  sol- 
uble in  alcohol,  only  slightly  soluble  in  water.  A  few  drops  of  the 
alcoholic  solution,  added  to  a  solution  of  hydrochloric  acid,  turns 
a  bright  cherry-red,  increasing  in  intensity  as  the  strength  of  the 
acid  solution  is  increased.  In  the  absence  of  free  hydrochloric  acid 
or  other  mineral  acid  the  solution  turns  a  bright  lemon-yellow. 

In  actual  practice  a  0.5  per  cent,  solution  of  the  substance  in 
alcohol  is  employed.  A  few  drops  of  this  solution  are  added  to 
the  stomach  contents,  which  need  not  be  filtered  for  this  purpose, 
or  to  the  residue  left  in  the  receptacle  in  which  the  stomach  con- 


DIMETHYL-AMIDO-AZO-BENZOL.  I49 

tents  were  received.  If  free  hydrochloric  acid  is  present  the  cherry- 
red  color  develops  and  spreads  in  beautiful  rings  from  each  drop 
of  the  indicator,  usually  leaving  in  the  center  a  clear,  yellow  area. 
In  case  the  indication  is  doubtful  the  following  modification  may  be 
employed :  A  small  porcelain  evaporating  dish  (or  white  butter 
plate)  is  thoroughly  rinsed  with  distilled  water  and  dried.  Upon 
one  side  of  the  dish  a  few  drops  of  the  filtrate  are  placed,  and  upon 
the  opposite  side  a  single  drop  of  the  indicator.  By  inclining  the 
dish  gently  the  two  solutions  may  be  made  to  mix,  and  at  the  line 
of  junction  the  cherry-red  color  may  be  seen,  the  white  background 
rendering  the  detection  of  the  tint  less  difficult. 

It  has  been  stated  by  Einhorn  and  others  that  this  test  is  liable 
to  mislead  in  cases  in  which  there  is  a  large  amount  of  organic 
acidity.  It  is  true  that  in  the  presence  of  lactic  acid  amounting  to 
0.2  per  cent,  or  more  in  gastric  juice  this  test  yields  a  red  color, 
resembling  that  due  to  inorganic  acids,  but  the  objection  is  more 
theoretical  than  real,  as  the  presence  of  such  an  amount  of  organic 
acids  seldom  occurs  in  the  stomach,  and  in  the  presence  of  proteids, 
peptones,  mucin,  etc.,  still  stronger  solutions  of  the  organic  acids 
are  required  to  produce  the  characteristic  reaction. 

Furthermore,  the  quantitative  estimation  of  organic  acidity  to  be 
described  presently  will  show  the  necessity  of  employing  further 
tests  for  the  presence  of  free  hydrochloric  acid,  on  account  of  a 
specially  great  acidity  of  organic  acids,  which  does  not,  as  a  rule, 
occur  in  a  stomach  secreting  a  normal  amount  of  hydrochloric  acid. 

The  Phloroglucin-vanillin  Test. — The  modification  of  this  test 
proposed  by  Boas  gives  the  most  satisfactory  results.  Two  gm. 
of  phloroglucin  and  one  gm.  of  vanillin  are  dissolved  in  lOO  gm.  of 
80  per  cent  alcohol.  The  solution  must  be  kept  in  a  dark-colored, 
well-stoppered  bottle,  as  the  solution  soon  decomposes  when  ex- 
posed to  the  light.  The  original  Giinzberg  formula  was  composed 
of  the  same  amount  of  the  ingredients  dissolved  in  30  c.c.  of  abso- 
lute alcohol.  This  solution  still  more  readily  undergoes  decompo- 
sition and  has  no  advantages  over  the  above  modification.  The 
solution  is  employed  in  the  following  manner  :  Four  or  five  drops 
of  the  reagent  are  mixed  on  a  small  porcelain  dish  or  small 
butter  plate  with  an  equal  amount  of  the  filtered  gastric  juice  or 
the  unfiltered  gastric  contents.  This  is  placed  on  a  waterbath, 
kept  just  below  the  boiling  point,  and  evaporated  slowly.  If  free 
hydrochloric  acid  be  present  in  the  proportion  of  0.5  pro  thousand 


150  RESORCIN    TEST    FOR    FREE    HCl. 

or  more,  a  fine  rose  tint  will  develop  at  the  edge  of  the  drop  where 
the  mixture  is  dried. 

The  mixture  may  be  evaporated  over  a  naked  flame  with  the 
same  results,  provided  the  temperature  is  not  raised  above  the 
boiling  point.  If  too  much  heat  is  applied,  a  brown  or  brownish- 
red  color  may  develop,  which  resembles  the  color  produced  where 
free  hydrochloric  acid  is  absent.  The  rose  color  produced  by  this 
reagent  comes  only  from  free  mineral  acids  ;  organic  acids,  acid 
salts,  combined  hydrochloric  acid,  peptone,  and  albumose  produce 
only  a  brawn  or  yellowish  discoloration. 

The  Resorcin  Test. — The  solution  consists  of  five  gm.  of 
resorcin  (resublimed),  and  three  gm.  of  cane  sugar  dissolved  in  100 
c.c.  of  94  per  cent,  alcohol.  Six  drops  of  the  filtered  gastric  juice 
and  three  drops  of  the  solution  are  mixed  on  a  porcelain  plate  and 
slowly  evaporated  as  in  the  phloroglucin-vanillin  (Giinzberg)  test. 
Care  must  be  employed  that  too  much  heat  is  not  applied,  as  heat- 
ing too  strongly  simply  yields  a  brown  or  black  deposit.  If  the 
operations  be  properly  conducted  and  free  hydrochloric  acid  be 
present,  a  fine  vermilion-red  line  forms  at  the  edge  of  the  drops, 
following  down  the  edge  of  the  solution  as  evaporation  proceeds, 
while  the  color  at  the  periphery  gradually  fades,  disappearing 
entirely  after  a  short  time,  leaving  a  reddish-brown  stain.  This 
test  has  the  same  degree  of  delicacy  as  the  phloroglucin-vanillin 
test  and  the  advantage  of  much  greater  stability,  retaining  its  deli- 
cacy for  months,  while  the  latter  lasts  only  a  few  weeks. 

Many  other  tests  might  be  mentioned,  some  of  thetn  much  less 
delicate,  among  them  Tropaeolin  00,  Mohr's  reagent,  methyl- 
violet,  and  emerald  green,  but  the  three  described  will  be  found 
the  most  reliable  and  easily  applied. 

Combined  Hydrochloric  Acid. — If  albuminous  bodies  are 
treated  with  a  weak  solution  of  hydrochloric  acid,  it  is  found  that 
a  certain  amount  of  the  hydrochloric  acid  combines  with  the  albu- 
minous bodies  to  form  compounds  which  do  not  give  the  reactions 
of  free  hydrochloric  acid.  In  other  words,  certain  affinities  of  the 
albuminous  substance  must  be  saturated  before  hydrochloric  acid 
appears  in  the  free  state.  In  the  stomach  the  same  reaction  must 
take  place,  except  probably  to  a  greater  extent,  due  to  the  more 
complicated  chemical  processes  through  which  these  substances 
pass.  This  is  shown  by  the  fact  that  even  after  a  simple  test-meal 
a  certain  amount  of  time  elapses  before  the  presence  of  free  hydro- 


LACTIC    ACID    FORMATION,    ETC.  I5I 

chloric  acid  can  be  demonstrated.  In  the  Ewald  meal,  from  twenty 
to  forty  minutes  elapse  before  free  hydrochloric  acid  can  be  dem- 
onstrated in  the  normal  individual,  while  in  the  more  complex 
meals  considerably  more  time  is  required.  This  form  of  hydro- 
chloric acid  is  important,  inasmuch  as  it  constitutes  a  part  of  the 
physiological  hydrochloric  acid,  and  stomach  digestion  will  pro- 
ceed in  a  fairly  normal  manner,  if  enough  hydrochloric  acid  is 
secreted  to  saturate  these  affinities,  while  not  enough  is  secreted  to 
form  the  excess  or  reserve  supply  called  free  hydrochloric  acid. 
It  is  evident,  therefore,  that  if  free  hydrochloric  acid  be  present,  all 
these  affinities  must  be  saturated,  while  in  its  absence  some 
hydrochloric  acid,  enough  to  more  or  less  saturate  these  affinities, 
may  have  been  secreted.  The  entire  absence  of  hydrochloric  acid, 
both  free  and  combined,  if  more  than  temporary,  is  a  serious 
condition,  indicating  an  atrophy  of  the  gastric  mucosa,  a  severe 
gastric  catarrh,  or  achylia  gastrica.  From  these  considerations  it 
will  be  seen  how  important  the  determination  of  the  combined 
hydrochloric  acid  is,  in  all  conditions  of  anacidity.  The  estimation 
and  quantitative  determination  of  the  combined  hydrochloric  acid 
will  be  deferred  to  the  paragraphs  devoted  to  the  quantitative 
determination  of  hydrochloric  acid. 

The  amount  of  pure  hydrochloric  acid  necessary  to  combine 
with  TOO  gm.  (or  100  c.c.)  of  the  various  food-stuffs  will  be  given 
in  the  chapter  on  the  Therapy  of  HCl. 

Lactic  Acid  ;  Formation,  Significance,  Detection. — It  was 
formerly  supposed  that  lactic  acid  was  secreted  by  the  stomach, 
but  by  the  more  accurate  investigations  of  later  years  it  has  been 
shown  beyond  doubt  that  lactic  acid  in  the  gastric  contents  is  either 
introduced  as  such  in  the  food  or  is  the  product  of  abnormal  fer- 
mentative changes  in  the  food  after  ingestion. 

Lactic  acid  may  be  introduced  in  food  either  as  sarcolactic  acid 
from  meat  or  fermentation  lactic  acid  found  in  bread  and  other 
starchy  foods.  Lactic  acid  may  be  formed  after  the  food  is  ingested, 
in  cases  of  carcinoma  of  the  stomach,  and  probably  also  in  small 
amounts  in  other  conditions,  of  subacidity  or  anacidity  associated 
with  deficient  motility. 

In  the  great  majority  of  cases  of  carcinoma  of  the  stomach 
lactic  acid  is  present  in  considerable  amounts,  except  in  those  cases 
in  which  the  motility  is  not  impaired.     In  such  cases  only  a  small 


152  RECOGNITION    OF    LACTIC    ACID. 

amount  of  lactic  acid  can  usually  be  demonstrated,  and  in  some 
cases  it  is  absent.  There  are  cases  of  carcinoma  of  the  fundus  or 
body  of  the  stomach  in  which  the  motility  is  so  good  that  at  the 
end  of  one  hour  no  remains  of  the  test-meal  can  be  regained. 

Small  traces  of  lactic  acid  can  usually  be  detected  for  some  time 
after  the  administration  of  the  Ewald  breakfast  or  similar  meals, 
though  at  the  height  of  digestion  the  usual  tests  are  negative,  due 
either  to  the  absorption  of  the  lactic  acid,  or  the  interference  of  free 
hydrochloric  acid,  or  the  products  of  digestion  with  the  delicacy  of 
the  tests.  In  cases  in  which  it  is  desirable  to  prove  the  formation 
of  lactic  acid  within  the  stomach,  it  is  necessary  to  employ  some 
meal  which  is  entirely  free  from  lactic  acid. 

Such  a  meal  has  been  proposed  by  Boas,  consisting  of  oatmeal 
srruel  to  which  only  a  little  salt  has  been  added.  The  stomach  is 
washed  out  on  the  evening  preceding  the  administration  of  the 
meal  until  no  food-particles  can  be  found,  the  gruel  given  in  the 
morning  and  the  contents  removed  one  hour  after. 

Only  rarely,  under  such  conditions,  is  any  notable  amount  of 
lactic  acid  to  be  demonstrated  except  in  cases  of  carcinoma  of  the 
stomach.  The  easiest  clinical  test  for  the  presence  of  lactic  acid  is 
that  of  Uffelmann.  Ten  c.c.  of  a  4  per  cent,  solution  of  carbolic 
acid  are  mixed  with  20  c.c.  of  water,  and  a  drop  of  a  strong 
solution  of  ferric  chlorid  added.  A  beautiful  amethyst-blue  color 
is  produced  which  turns  a  canary-yellow  when  treated  with  a  solu- 
tion of  lactic  acid  or  gastric  juice  containing  lactic  acid.  The 
delicacy  of  this  test  is  interfered  with  by  the  presence  of  free 
hydrochloric  acid  and  peptones.  Glucose,  acid  phosphates,  and 
alcohol  give  a  reaction  resembling  that  of  lactic  acid,  butyric  acid 
giving  a  much  lighter  tint.  In  case  of  doubt,  a  modification  that 
has  given  good  results  is  the  following :  Five  or  ten  c.c.  of  the 
filtered  gastric  juice  are  treated  with  ten  times  its  volume  of  ether, 
free  from  alcohol,  and  then  shaken  in  a  stoppered  separating  funnel 
for  fifteen  or  twenty  minutes  and  allowed  to  stand  till  the  layers 
have  separated.  The  ethereal  solution  is  allowed  to  evaporate,  the 
residue  dissolved  in  five  or  ten  c.c.  of  water,  and  the  solution  tested 
for  lactic  acid  as  above.  While  this  test  is  not  a  very  delicate  one, 
lactic  acid  when  present  in  considerable  amounts  gives  a  more 
decided  reaction  than  any  of  the  substances  mentioned  as  having  a 
similar  reaction,  and  it  is  a  good  test  for  clinical  purposes. 


DETECTION    OF    LACTIC    ACID.  1 53 

Boas'  method  is  to  be  employed  in  doubtful  cases.  This  method 
is  based  upon  the  fact  that  when  lactic  acid  is  treated  with  strong 
oxidizing  agents,  formic  acid  and  acetic  aldehyd  are  formed. 

CgHgOg  =  CH3COH  4-  HCOOH. 

Acetic  aldehyd  may  be  easily  recognized  by  its  action  on  Ness- 
ler's  reagent,  or  upon  an  alkaline  solution  of  iodin  in  iodid  of 
potassium.    Nessler's  reagent  is  prepared  in  the  following  manner: 

One  hundred  c.c.  of  a  four  per  cent,  solution  of  iodid  of  potas- 
sium is  warmed,  and  while  warm  treated  with  iodid  of  mercury 
until  a  small  amount  remains  undissolved.  After  cooling,  40  c.c. 
of  water  are  added.  Two  parts  of  this  solution  are  then  treated 
with  three  parts  of  a  strong  solution  of  caustic  potash  ;  any  precipi- 
tate which  may  form  is  filtered  off  and  the  reagent  kept  in  a  well- 
stoppered  bottle. 

The  solution  of  iodin  is  prepared  by  mixing  a  solution  of  iodin 
in  iodid  of  potassium  with  caustic  potash  or  potassium  carbonate. 

Metliod. — The  filtered  gastric  juice  is  tested  for  the  presence  of 
free  acids  as  above,  and,  if  present,  10  or  20  c.c.  are  treated  with  an 
excess  of  barium  carbonate.  If  no  free  acids  are  present,  this  is  not 
necessary.  The  solution  is  now  evaporated  to  a  syrup  on  the 
waterbath  to  drive  off  the  fatty  acids.  The  syrup  is  treated  with 
a  few  drops  of  phosphoric  acid  and  brought  to  a  boiling  point  to 
expel  carbon  dioxid.  After  cooling,  it  is  extracted  with  100  c.c.  of 
ether  by  shaking  for  half  an  hour.  After  standing  for  a  short  time 
to  allow  separation  to  take  place,  the  ethereal  layer  is  drawn  off 
and  evaporated  (avoiding  a  flame),  the  residue  taken  up  in  45  c.c.  of 
water,  shaken  and  filtered.  The  filtrate  is  treated  in  an  Erlemeyer 
flask  with  five  c.c.  of  strong  sulphuric  acid  and  as  much  black  oxid 
of  manganese  as  will  lie  on  the  point  of  a  knife-blade.  The  flask 
is  closed  with  a  perforated  stopper,  in  which  is  placed  a  bent  glass 
tube,  the  long  arm  passing  into  a  cylinder  filled  with  10  or  15  c.c.  of 
Nessler's  reagent  or  alkaline  iodin  solution  prepared  as  described. 
Carefully  heat  the  flask,  and  if  lactic  acid  is  present,  aldehyd  will 
distil  over  forming  aldehyd  mercury,  yellowish-red  in  color,  if 
Nessler's  reagent  is  used,  and  yellowish  crystals  of  iodoform,  which 
may  be  recognized  by  their  odor,  if  the  alkaline  solution  of  iodin  is 
employed. 

Butyric   acid  can    usually   be    determined    by    its    odor    alone, 
which  is  that  of  rancid   butter.     In  case  of  doubt,  ten  c.c.  of  the 
II 


154  DETECTION    OF    ACETIC    ACID. 

gastric  juice  are  extracted  with  50  c.c.  of  ether,  the  ethereal  solution 
evaporated,  and  the  residue  taken  up  with  water.  The  odor  is  more 
evident  in  this  concentrated  aqueous  solution.  A  small  amount  of 
calcium  chlorid  causes  the  separation  of  an  oily  layer  of  butyric 
acid  ;  strong  mineral  acids  also  separate  the  oily  layer  or  drops  of 
the  acid. 

Acetic  acid  may  also  be  detected  by  its  odor. 

Ten  c.c.  of  the  gastric  juice  are  extracted  with  ether,  the  ether 
evaporated,  the  residue  taken  up  with  a  small  amount  of  water, 
accurately  neutralized  with  caustic  soda  solution,  and  mixed  with 
a  few  drops  of  a  very  dilute  solution  of  ferric  chlorid.  In  the 
presence  of  acetic  acid  this  gives  a  dark-red  color. 

The  ethereal  residue  after  evaporation  is  taken  up  with  a  small 
amount  of  strong  sulphuric  acid  and  alcohol.  If  acetic  acid  is 
present,  the  fragrant  odor  of  ethyl  acetate  is  easily  detected. 

Fatty  acids  do  not  occur  normally  in  the  stomach  contents. 
Butyric  acid  may  be  formed  when  a  large  amount  of  milk  or  car- 
bohydrates have  been  ingested,  usually  associated  with  an  excess 
of  lactic  acid.  It  has  been  shown  also  that  butyric  acid  can  be 
formed  from  lactic  acid. 

Acetic  acid,  on  the  contrary,  is  a  product  of  alcohol,  and  may  be 
formed  from  alcohol  ingested  or  from  alcohol  produced  by  the  ac- 
tion of  yeast  upon  the  sugar  contained  in  the  stomach  contents. 
Hence  it  follows  that  it  is  necessary  to  exclude  alcoholism  before 
significance  is  attached  to  the  presence  of  acetic  acid  in  the  stomach 
contents.  If,  in  the  case  of  acetic  acid,  alcoholism  be  excluded, 
and,  in  the  case  of  butyric  acid,  the  ingestion  of  butter  or  fats  in 
general  be  excluded,  the  presence  of  these  acids  has  the  same  sig- 
nificance as  the  occurrence  of  lactic  acid,  viz.,  stenosis  of  the 
pylorus  with  dilatation  and  fermentation. 


CHAPTER    XVII. 

QUANTITATIVE  ANALYSIS  OF  THE  STOMACH  ACIDS. 

Numerous  methods  have  been  devised  for  the  estimation  of  the 
amount  of  free  hydrochloric  acid  present  in  the  gastric  juice.  The 
most  convenient  method  of  estimation  for  clinical  purposes  is  that 
of  Topfer,  which  at  the  same  time  estimates  the  acidity  due  to 
organic  acids  and  acid  salts,  and  that  due  to  the  combined  hydro- 
chloric acid. 

Topfer' s  Method. — Three  indicators  are  used  in  this  method: 
I    A  0.5    per    cent,   alcoholic    solution    of    dimethyl-amido-azo- 
benzol. 

2.  A  one  per  cent,  aqueous  solution  of  alizarin  (alizarin  mono- 
sulphonate  of  sodium). 

3.  A  one  per  cent,  alcoholic  solution  of  phenolphthalein. 

1.  As  has  been  mentioned  under  the  head  of  tests  for  free  hydro- 
chloric acid,  dimethyl-amido-azo-benzol  reacts  to  very  faint  traces 
of  mineral  acids,  particularly  h}-drochloric,  but  to  organic  acids 
only  when  present  in  \'ery  large  amounts,  and  not  at  all  to  com- 
bined hydrochloric  acid  or  acid  salts.  It  will  be  seen  that  by  this 
indicator  we  can  easily  find  the  amount  of  free  hydrochloric  acid. 
Topfer's  method  gives  results  as  reliable  as  those  of  the  improved 
Sjoqvist's  or  Braun's  method,  according  to  Paul  Hari  {Arch.  f.  Ver- 
dmmngskrankheiten,  Bd.  11,  S.  332). 

Ten  c.c.  of  the  filtered  gastric  juice  are  measured  into  a  small 
clean  flask,  and  a  few  drops  of  dimethyl-amido-azo-benzol  added. 
The  solution  turns  a  bright  red  in  the  presence  of  free  hydrochloric 
acid.  The  solution  is  now  titrated  with  a  decinormal  solution  of 
caustic  soda  (prepared  as  above),  until  the  red  color  of  the  solution 
changes  to  a  clear  yellow. 

2.  Into  a  second  beaker  or  flask  ten  c.c.  of  the  gastric  juice  are 
measured,  a  {^w  drops  of  the  alizarin  solution  added,  and  the  solu- 
tion titrated  with  the  decinormal  solution  of  caustic  soda  until  the 
solution  turns  to  a  clear  violet  color. 

As  this  tint  is  difficult  for  the  unpracticed  eye  to  recognize, 
Topfer  recommends  the  following  preliminary  tests  : 

155 


156  topher's  method. 

(a)  To  five  c.c.  of  distilled  water  add  two  or  three  drops  of  the 
alizarin  solution.     A  clear  yellow  color  results. 

(d)  To  five  c.c.  of  a  one  per  cent,  solution  of  disodium  phosphate 
add  the  alizarin  solution  as  above.  A  reddish  color  with  a  slight 
tinge  of  violet  results. 

(c)  Five  c.c.  of  a  one  per  cent,  solution  of  sodium  carbonate 
when  treated  with  alizarin,  as  above,  give  a  clear  violet  tint,  which 
is  the  tint  to  be  reached  in  the  titration.  Until  the  e}-e  becomes 
accustomed  to  the  reaction,  it  is  well  to  prepare  this  solution  as  a 
guide  in  the  titration. 

3.  To  a  third  portion  (ten  c.c.)  of  the  filtered  gastric  juice  two  or 
three  drops  of  phenolphthalein  solution  are  added  and  the  solution 
titrated  with  the  decinormal  solution  of  caustic  soda.  After  a  cer- 
tain amount  of  the  solution  has  been  added,  a  light-rose  color 
develops,  which  is  not,  however,  the  end  of  the  reaction.  It  will 
be  noticed  that  as  the  drop  of  caustic  soda  solution  falls  into  the 
solution,  a  dark-red  color  is  produced  at  the  point  of  contact, 
fading  into  rose  color  on  agitation.  The  titration  must  be  carried 
on  until  the  entire  solution  has  reached  this  color  and  no  line  of 
separation  can  be  made  out  on  adding  a  drop  of  the  caustic  soda 
solution. 

There  are  two  ways  of  stating  the  result  of  the  titrations.  The 
simplest  method  is  to  state  the  number  of  c.c.  of  the  caustic  soda 
solution  which  would  be  necessary  to  neutralize  lOO  c.c.  of  the 
gastric  juice,  as  that  number  of  degrees  of  acidity.  For  example, 
the  number  of  c.c.  of  the  caustic  soda  solution  necessary  to  neu- 
tralize ten  c.c.  of  the  gastric  juice,  using  dimethyl-amido-azo-benzol 
as  an  indicator,  is  2.3  c.c.  One  hundred  c.c.  would  then  require 
ten  times  that,  the  amount  of  acidity  being  stated  as  23  degrees 
=  23  c.c. 

The  second  method  of  stating  the  results  is  to  give  the  amount 
of  acid  per  thousand  in  terms  of  hydrochloric  acid.  As  each  c.c. 
of  the  solution  of  caustic  soda  will  neutralize  0.00365  gm.  of  pure 
hydrochloric  acid,  the  above  example  would  show  0.8395  gm.  of 
hydrochloric  acid  per  thousand,  or  0.08395  per  cent. 

As  an  example  of  the  calculations  employed  in  Topfer's  method, 
let  us  suppose  that  in  the  titration  (i)  with  dimethyl-amido-azo- 
benzol  as  an  indicator,  3.5  c.c.  of  caustic  soda  solution  were  em- 
ployed, (2)  with  alizarin  4.9  c.c.  of  the  caustic  soda  solution  were 
required,  and  (3)  with  phenolphthalein  7.5  c.c.  of  caustic  soda  solu- 


MARTIUS    AND    LUTTKE's    METHOD.  15/ 

tion  were  required  to   produce  the  proper  tint,  using  in  each  case 
ten  c.c.  of  the  stomach  contents. 

1.  As  dimethyl-amido-azo-benzol  reacts  only  with  free  hydro- 
chloric acid,  the  acidity  referable  to  this  is  35  degrees,  or  .12775 
per  cent. 

2.  Alizarin  shows  the  tint  of  an  alkaline  reaction  when  the  free 
hydrochloric  acid,  organic  acids,  and  acid  salts  have  been  neutral- 
ized, combined  hydrochloric  acid  having  no  effect  upon  it.  Hence 
it  follows  that  by  subtracting  the  amount  of  free  hydrochloric  acid 
from  the  acidity  found  by  alizarin,  the  amount  of  acidity  due  to 
organic  acids  and  acid  salts  will  be  found,  in  this  case  49  —  35  =  14 
degrees,  or  .0511  per  cent. 

3.  Phenolphthalein  only  turns  to  a  dark-red  color  when  all  the 
acidities  of  the  solution  have  been  saturated,  including  the  combined 
hydrochloric  acid.  The  amount  of  combined  hydrochloric  acid 
may  be  found  by  subtracting  the  acidity  found  by  alizarin  from 
that  found  by  phenolphthalein,  in  this  case  75  —  49  =  26  degrees, 
or  .0949  per  cent. 

Method  of  Martius  and  Liittke. — By  this  method  the  amount 
of  physiological  hydrochloric  acid,  the  free  and  combined  hydro- 
chloric acid,  are  found,  as  well  as  the  total  chlorin  of  the  gastric 
juice,  by  determination  of  the  amount  of  chlorin.  The  method  is 
based  upon  the  fact  that  by  moderate  incineration  the  free  hydro- 
chloric acid  can  be  driven  off,  while  the  chlorin  in  combination 
with  the  inorganic  bases  is  not  affected. 

For  this  method  the  following  solutions  are  required  : 

1.  A  decinormal  solution  of  hydrochloric  acid,  which  can  be 
prepared  by  standardizing  against  the  decinormal  caustic  soda  solu- 
tion as  described  in  a  former  chapter. 

2.  A  decinormal  solution  of  nitrate  of  silver,  containing  25  per 
cent,  of  pure  nitric  acid.  This  solution  is  approximately  made  up 
by  dissolving  17  gm.  of  pure  crystallized  nitrate  of  silver  in  900  c.c. 
of  a  25  per  cent,  solution  of  nitric  acid,  and  adding  50  c.c.  of  the 
liquor  ferri  sulphur  oxydati  of  the  German  Pharmacopeia  (the 
liquor  ferri  oxysulphatis  ["  National  Formulary,"]  will  serve  the 
same  purpose).  The  solution  is  then  standardized  against  the 
solution  of  hydrochloric  acid  and  diluted  to  the  proper  volume. 
Each.  c.c.  of  the  solution  is  equivalent  to  0.00365  gm.  of  pure 
hydrochloric  acid. 

3.  A  decinormal  solution  of  ammonium  sulphocyanate.     Eight 


158  ANALYSIS    OF    THE    STOMACH    ACIDS. 

gm.  of  the  pure  salt  are  dissolved  in  900  c.c.  of  distilled  water  and 
titrated  against  the  decinormal  solution  of  silver  nitrate.  After 
ascertaining  the  strength  of  this  solution  it  is  diluted  so  that  it  is 
exactly  equivalent  to  the  decinormal  solution  of  nitrate  of  silver. 

Method. —  I.  To  determine  the  total  amount  of  chlorin  present  in 
the  gastric  juice,  ten  c.c.  of  the  stomach  contents,  after  thorough 
mixing,  are  measured  into  a  small  cylinder  graduated  to  100  c.c, 
and  treated  with  20  c.c.  of  the  solution  of  nitrate  of  silver.  The 
mixture  is  thoroughly  shaken  and  allowed  to  stand  for  ten  minutes. 
The  mixture  is  then  diluted  to  100  c.c,  once  more  agitated,  and 
filtered  through  a  dry  filter  into  a  dry  flask.  Fifty  c.c.  of  the  filtrate 
are  then  titrated  with  the  decinormal  solution  of  ammonium  sul- 
phocyanate  until  a  permanent  red  color  appears.  Multiply  the 
number  of  c.c.  of  ammonium  sulphocyanate  by  two,  as  only  half 
the  filtrate  was  taken,  and  subtract  from  the  number  of  c.c.  of 
nitrate  of  silver  added  (20) ;  the  result  will  be  the  number  of  c.c. 
of  the  nitrate  of  silver  solution  precipitated  by  the  total  chlorin  of  the 
gastric  juice  and  correspond  to  the  same  number  of  c.c.  of  deci- 
normal solution  of  hydrochloric  acid,  the  whole  amount  of  chlorin 
being  expressed  in  terms  of  hydrochloric  acid. 

2.  To  determine  the  amount  of  chlorin  in  combination  with  in- 
organic bases. 

Ten  c.c.  of  the  filtered  gastric  juice,  or  of  the  well-mixed  stomach 
contents,  are  evaporated  to  dryness  in  a  platinum  or  porcelain  cru- 
cible, over  a  water-bath  or  on  a  plate  of  asbestos,  to  avoid  loss  from 
sputtering.  The  incineration  is  carried  only  to  the  point  when  the 
residue  ceases  to  burn  with  a  luminous  flame.  After  cooling,  the 
residue  is  treated  with  distilled  water  up  to  about  100  c.c,  or  until 
the  filtrate  comes  away  free  from  chlorids,  which  may  be  shown 
by  treating  with  a  drop  of  silver  nitrate.  If  the  filtrate  remains 
perfectly  clear  after  the  addition  of  a  drop  of  nitrate  of  silver,  the 
residue  is  free  from  chlorids.  To  the  clear  filtrate  is  now  added 
ten  c.c.  of  the  decinormal  solution  of  nitrate  of  silver,  and  the 
excess  titrated  by  means  of  the  decinormal  solution  of  ammonium 
sulphocyanate  as  before.  The  amount  of  ammonium  sulphocyanate 
solution  subtracted  from  the  amount  of  the  silver  solution  (ten  c.c.) 
gives  the  amount  of  silver  precipitated  by  the  chlorids  remaining 
after  incineration  in  combination  with  the  inorganic  bases.  By 
subtracting  the  result  of  the  second  process  from  that  of  the  first, 
the  amount  of  free  and  combined  hydrochloric  acid  is  determined. 


LEO  S    METHOD.  I  59 

Modifications. — i.  By  titrating  with  decinormal  caustic  soda  solu- 
tion, using  dimethyl-amido-azo-benzol  as  an  indicator,  we  obtain 
the  amount  of  free  hydrochloric  acid  ;  this  subtracted  from  the 
sum  of  the  free  and  combined  hydrochloric  acid  together,  as  arrived 
at  by  the  method  No.  2  on  previous  page,  will  give  the  amount  of 
combined  hydrochloric  acid. 

2.  By  determining  the  total  acidity  with  phenolphthalein  and  sub- 
tracting from  it  the  amount  of  free  and  combined  hydrochloric  acid, 
we  can  estimate  the  acidity  due  to  organic  acids  and  acid  salts. 

3.  The  amount  of  organic  acid  present  may  be  estimated  in 
terms  of  hydrochloric  acid  by  the  method  of  Hehner-Seeman  (to 
be  described  later).  This  result  deducted  from  the  result  of  the 
preceding  modification  gives  the  amount  of  acidity  due  to  acid  salts. 

Leo's  Method. — Leo  bases  his  method  upon  the  fact  that  when 
calcium  carbonate  is  added  in  a  fine  powder  to  the  gastric  juice,  the 
free  and  combined  hydrochloric  acid  combine  with  the  calcium  car- 
bonate to  form  calcium  chlorid,  a  neutral  salt,  while  the  acid  salts 
are  not  affected.  During  the  reaction,  however,  the  calcium  chlorid 
reacts  with  the  phosphates  to  form  acid  calcium  phosphate  (mono- 
calcium  phosphate,  CaHPOj).  As  this  requires  double  the  amount 
of  caustic  soda  solution  to  neutralize  that  would  be  required  for  the 
acid  sodium  phosphate,  it  is  necessary  to  add  each  time  an  excess 
of  calcium  chlorid  solution  before  titration. 

Method. — Ten  c.c.  of  the  gastric  juice  are  shaken  up  with  50  c.c. 
of  ether  to  remove  organic  acids.  The  residue  after  drawing  off 
the  ethereal  layer  is  treated  with  five  c.c.  of  a  concentrated  solu- 
tion of  calcium  chlorid  and  titrated  with  the  decinormal  solution 
of  caustic  soda,  using  phenolphthalein  as  an  indicator.  This  deter- 
mines the  acidit}'  due  to  free  and  combined  hydrochloric  acid  and 
to  acid  salts.  A  second  portion  of  15  c.c.  is  treated  with  a  small 
amount  of  pure,  dry  calcium  carbonate,  the  mixture  stirred  and 
immediately  filtered  through  a  dry  filter.  The  carbon  dioxid 
is  expelled  from  the  filtrate  by  passing  a  current  of  air  through  it. 
Ten  c.c.  of  the  filtrate  are  then  treated  with  five  c.c.  of  the  saturated 
solution  of  calcium  chlorid  and  titrated  as  above.  The  acidity 
found  is  due  to  the  acid  phosphates.  By  subtracting  the  result 
found  in  the  second  titration  from  that  of  the  first,  the  amount  of 
free  and  combined  hydrochloric  acid  is  determined. 

Boas'  Method. — This  method  is  an  easily  applied  test  for  free 
hydrochloric  acid,  which  gives  fairly  accurate  results  in  the  absence 


i6o 


QUANTITATIVE    ESTIMATION    OF    LACTIC    ACID. 


-25  c.c. 


of  organic  acids  or  when  they  are  present  only  in  traces.  Ten  c.c. 
of  the  filtered  gastric  juice  are  titrated  with  decinormal  caustic  soda 
solution  until  a  small  amount  (a  drop)  removed  by  a  platinum  loop 
fails  to  change  the  tint  of  Congo  paper.  Instead  of  using  the  paper 
as  an  indicator  outside,  a  small  bit  of  the  Congo  paper  may  be 
dropped  into  the  solution  and  the  titration  conducted  slowly,  with 
constant  shaking,  until  the  paper  regains  its  original  red  color. 
This  test,  however,  can  not  be  employed  in  the  presence  of  any 
considerable  amount  of  free  organic  acids. 

Lactic  Acid — Quantitative  Estimation. 
— A  simple  clinical  test  for  lactic  acid  has 
been  devised  by  Strauss  [Berlin,  klin.  Woc/i., 
1895,  No.  37).  A  separating  funnel  is  gradu- 
ated to  five  c.c.  below  and  25  c.c.  above. 
The  funnel  is  filled  to  the  five  c.c.  mark  with 
gastric  juice  and  ether  added  to  the  25  c.c. 
mark.  The  funnel  is  corked  and  well 
shaken,  and  after  standing  for  a  short  time 
to  allow  the  fluids  to  separate,  the  liquids 
are  run  out  to  the  five  c.c.  mark.  Distilled 
water  is  added  to  the  25  c.c.  mark  and  the 
mixture  treated  with  two  drops  of  a  solution 
of  the  officinal  tincture  of  the  chlorid  of  iron, 
diluted  I  :  10.  On  shaking  the  mixture,  an 
intense  green  color  is  produced  if  lactic  acid 
is  present  in  the  proportion  of  i  per  looo  or 
more.  If  present  in  the  proportion  of  from 
0.5  to  I  per  1000  only  a  pale-green  color  is 
produced. 

Boas'    Method. — This    method  of   esti- 
mating the   amount  of  lactic  acid   depends 
upon    its   oxidation    into   aldehyd    and  the 
estimation    of    the    latter    by    means    of  a 
standard  solution  of  iodin. 
Solutions  required  :    I.  A  decinormal  solution  of  iodin  is  prepared 
by  dissolving  25  gm.  of  potassium  iodid  in  about  200  c.c.  of  water, 
and  dissolving  in  this  12.6  gm.  of  resublimed  iodin.     The  solution 
is  diluted  with  distilled  water  to  1000  c.c,  and  requires  no  correction, 
2.  A    decinormal    solution  of  sodium    arsenite:    Dissolve    16.5 
gm.  of  sodium  arsenite  in  about  900  c.c.  of  distilled  water.     It  is 


-5  c.c. 


Fig.  23  — Strauss'  Mixing 
Funnel  for  Lactic  Acid 
Determinations. 


DETERMINATION    OF    FATTY    ACIDS.  l6l 

then  titrated  against  the  decinormal  solution  of  iodin  and  diluted  so 
that  the  two  solutions  are  equivalent. 

3.  Hydrochloric  acid  (sp.  gr.  1018). 

4.  Normal  solution  of  potassium  hydrate  (56  gm.  in  1000  c.c). 
Method  :  Ten  or  20  c.c.  of  the  filtered  gastric  juice  are  tested  for 

the  presence  of  free  acid  ;  if  present,  a  small  amount  of  barium  car- 
bonate is  added  (if  free  acid  be  absent,  this  addition  is  unnecessary), 
and  evaporated  to  a  syrup.  A  few  drops  of  phosphoric  acid  are 
added  and  the  solution  boiled  slightly  to  expel  carbon  dioxid. 

Allow  the  syrup  to  cool  ;  extract  with  100  c.c.  of  ether  free  from 
alcohol ;  after  the  two  fluids  have  separated  draw  off  the  ethereal 
solution;  evaporate;  take  up  the  residue  in  45  c.c.  of  water,  and 
filter.  The  filtrate  is  treated  in  an  Erlemeyer  flask  with  five  c.c.  ol 
sulphuric  acid  and  a  small  amount  of  manganese  dioxid.  The  flask 
is  closed  by  a  two-holed  rubber  stopper,  one  aperture  being  closed 
by  a  glass  tube  and  rubber  tubing  clamped  off,  the  other  opening 
receiving  a  bent  glass  tube  leading  to  the  distilling  apparatus.  The 
distillate  is  received  in  a  large  flask  well  stoppered.  The  mixture 
is  distilled  at  a  gentle  heat  until  about  four-fifths  of  the  fluid  has 
passed  over.  The  distillate  is  then  treated  with  20  c.c.  of  the  deci- 
normal solution  of  iodin  and  the  same  amount  (20  c.c.)  of  the  nor- 
mal potassium  hydrate  solution,  thoroughly  shaken  and  allowed  to 
stand  for  a  few  minutes  in  the  flask.  Twenty  c.c.  of  hydrochloric 
acid  and  an  excess  of  sodium  bicarbonate  in  powder  are  then 
added,  and  the  excess  of  iodin  determined  by  titration  with  the  so- 
lution of  sodium  arsenite.  The  sodium  arsenite  is  added  until  the 
solution  is  decolorized  ;  fresh  starch  solution  and  the  iodin  solution 
is  then  added  until  the  blue  color  becomes  permanent.  Each  c.c. 
of  the  iodin  solution  in  excess  of  the  sodium  arsenite  solution  is 
equivalent  to  0.003388  gm.  of  lactic  acid. 

Fatty  Acids. — The  method  of  Cahn  and  Mehring  modified  by 
McNaught  is  simple  and  fairly  accurate.  The  total  acidity  is  de- 
termined in  ten  c.c.  of  the  filtered  gastric  juice  by  titrating  with  a 
decinormal  solution  of  caustic  soda,  using  phenolphthalein  as  an 
indicator.  Ten  C;C,  are  evaporated  to  a  syrup  on  the  water-bath, 
made  up  to  the  original  volume  with  distilled  water,  and  the  acidity 
determined  as  before.  The  difference  in  acidity  will  be  the  amount 
due  to  fatty  acids. 

Total  Organic  Acids. — The   total  organic  acids  are  best   esti- 


1 62  ANALYSIS    OF    THE   STOMACH    ACIDS. 

mated  by  the  method  of  Hehner-Seeman,  called,  by  Leube,  Braun's 
method. 

Ten  c.c,  of  the  gastric  juice  are  accurately  neutralized  with  a 
decinormal  solution  of  caustic  soda,  using  phenolphthajein  as  an 
indicator.  This  solution  is  then  evaporated  to  dryness,  carefully 
avoiding  sputtering,  and  incinerated  as  long  as  the  residue  burns 
with  a  luminous  flame.  After  cooling,  the  residue  is  extracted 
with  boiling  distilled  water,  filtered,  and  the  amount  of  sodium  car- 
bonate formed  determined  by  titration  with  a  decinormal  solution 
of  hydrochloric  acid.  As  the  presence  of  free  carbon  dioxid  inter- 
feres somewhat  with  the  delicacy  of  the  reaction  when  phenol- 
phthalein  is  used  as  an  indicator,  the  following  modification  has 
given  better  results  :  After  the  incinerated  mass  has  been  extracted 
with  boiling  water  and  filtered,  a  known  excess  of  the  decinormal 
solution  of  hydrochloric  acid  is  added,  the  solution  boiled  to  expel 
any  carbon  dioxid  in  solution,  and  the  excess  of  acid  determined 
by  back  titration  with  a  decinormal  solution  of  caustic  soda. 

This  method  is  based  upon  the  fact  that  when  salts  of  the 
organic  acids  with  the  alkalies  are  incinerated  at  a  low  heat,  the 
carbonates  'of  the  alkalies  are  formed  with  the  liberation  of  water 
and  carbon  dioxid.  This  method  is  simple.  Martins  and  Liittke 
speak  favorably  of  it,  and  Hemmeter  has  obtained  accurate  results 
with  it. 


CHAPTER  XVIII. 

DIGESTIVE  FERMENTS.— PRODUCTS  OF  DIGESTION.— 
TESTS  FOR  SAME. 

Saliva. — The  saliva  as  found  in  the  mouth  is  the  mixed  secre- 
tions of  all  the  salivary  glands.  It  may  be  readily  obtained  for 
testing  by  requesting  the  individual  under  examination  to  chew  a 
piece  of  soft  rubber  or  other  insoluble  substance,  to  stimulate  the 
secretion,  and  as  it  forms  it  is  placed  in  a  clean  receptacle.  It  is 
a  clear,  slightly  opalescent  fluid,  of  a  mucoid  consistency,  having  a 
specific  gravity  of  1002  to  1006.  Under  normal  conditions  it  has  a 
slight  alkaline  reaction,  its  alkalinity  averaging  in  man  0.08  per 
cent.,  expressed  as  sodium  carbonate  (Chittenden). 

Its  active  constituent,  ptyalin,  acts  most  readily  upon  boiled 
starch,  raw  starch  being  protected  from  its  action  by  the  coating  of 
cellulose  surrounding  each  granule.  Its  action  is  entirely  amylo- 
lytic,  as  it  has  no  action  upon  other  food-products. 

Its  action  upon  starch  may  be  demonstrated  in  the  following 
simple  manner :  A  few  c.c.  of  boiled  starch  paste  are  treated  in  a 
test-tube  with  a  small  amount  of  saliva.  A  few  drops  removed  and 
treated  on  a  testing  plate  with  a  drop  of  iodin  solution  give  the 
characteristic  blue  color  of  starch.  After  a  moment  or  two  a  few 
drops  removed  will  show  a  violet  color,  and  by  treating  a  portion 
at  intervals  the  color  changes  gradually  to  a  deep  reddish-brown, 
and  finally  disappears.  Different  products  of  the  action  of  the  fer- 
ment are  found  at  different  stages  of  digestion.  The  violet  color 
first  found  is  a  color  which  results  from  a  mixture  of  erythrodex- 
trin  and  starch  when  treated  with  iodin.  Later  the  color  becomes 
reddish-brown,  due  to  the  change  of  the  starch  entirely  into  dex- 
trins  and  sugar.  When  digestion  has  gone  on  until  the  solution 
gives  no  color  whatever  with  iodin,  the  solution  still  contains  some 
form  of  dextrin  (achroodextrin),  as  may  be  shown  by  the  addition 
of  alcohol,  which  throws  down  a  profuse  white  precipitate.  It  may 
be  shown,  also,  that  the  solution  contains  sugar  by  treating  a  small 
amount  of  the  mixture  with  Fehling's  solution.     This  sugar,  ac- 

163 


164  TESTS    FOR    PTYALIN. 

cording  to  the  investigations  of  Nasse,  von  Mehring,  and  Musculus, 
is  not  dextrose,  as  formerly  taught,  but  maltose. 

The  action  of  ptyalin  is  most  energetic  at  the  temperature  of  the 
body.  It  acts  best  in  a  neutral  medium,  though  a  small  trace  of 
alkali  has  little  or  no  effect  upon  it.  Its  activity  is  stimulated  by 
the  addition  of  enough  acid  to  combine  with  its  proteid  constitu- 
ents. A  minute  trace  of  acid  still  allows  the  action  to  continue, 
but  for  practical  purposes  we  may  say  that  the  addition  of  free 
acids,  in  such  quantity  as  are  found  in  the  gastric  juice,  not  only 
stop  its  action,  but  possibly  destroy  the  ferment,  so  that  after 
neutralization  it  is  no  longer  able  to  digest  starch. 

In  the  stomach,  the  action  of  the  ptyalin  probably  continues 
until  the  presence  of  free  acid  destroys  the  ferment.  As  no  free 
acid  can  be  demonstrated  in  the  stomach  until  the  lapse  of  fifteen 
or  twenty  minutes  normally,  the  greater  portion  of  the  starch  is 
transformed  into  sugar  and  achroodextrin.  Under  normal  condi- 
tions, then,  we  should  find  in  the  gastric  juice  removed  for  exami- 
nation, sugar,  achroodextrin,  and  a  faint  trace  of  erythrodextrin. 
The  presence  of  a  marked  reaction  of  erythrodextrin,  then,  is  valua- 
ble presumptive  evidence  of  hyperacidity,  its  absence  indicating 
either  normal  acidity  or  subacidity. 

Only  in  rare  instances  has  absence  of  ptyalin  from  the  saliva 
been  seen. 

There  are  some  unexplained  cases  in  which,  with  a  normal  or 
diminished  acidity,  the  digestion  of  starches  is  very  poor,  as  is 
shown  by  the  marked  reaction  of  erythrodextrin  and  the  small 
percentage  of  sugar  found  by  quantitative  test.  The  activity  of  the 
salivary  excretion  ought  always  to  be  examined  in  such  cases. 

Pepsin. — The  proteolytic  ferment  of  the  gastric  juice  is  active 
only  in  an  acid  medium,  and  is  destroyed  by  very  dilute  solutions 
of  the  alkaline  carbonates.  Pepsin  is  probably  not  secreted  as  such, 
its  precursor  being  pepsinogen  or  propepsin,  which  is  transformed 
by  weak  acids  into  the  active  ferment,  pepsin.  While  hydrochloric 
acid  acts  best  in  thus  transforming  pepsinogen  into  pepsin,  other 
acids  to  a  lesser  degree  can  perform  the  office.  Pepsin,  like  the 
other  ferments,  has  the  property  of  changing  an  almost  unlimited 
amount  of  proteids,  providing  the  products  of  its  action  are  removed 
when  formed,  and  the  temperature  kept  at  a  favorable  point,  as  it 
appears  to  act  by  its  presence,  not  being  itself  destroyed  or  changed 
by  the  reaction. 


TESTS    FOR    PEPSIN.  1 65 

While  no  quantitative  methods  have  been  devised,  and  it  has 
never  been  isolated  in  a  pure  state,  we  know  that  a  product  can  be 
obtained  by  complex  chemical  methods  which,  while  intensely 
proteolytic,  exhibits  none  of  the  reactions  of  proteids,  so  that  the 
ferment,  whatever  its  nature,  probably  is  not  a  proteid. 

The  only  tests  which  can  be  used  for  its  detection,  therefore,  are 
of  a  qualitative  nature:  its  effect  in  acid  solution  on  proteid  sub- 
stances. Comparative  tests  may  also  be  instituted,  using  for  com- 
parison gastric  juice  from  a  healthy  stomach. 

The  amount  of  acid  necessary  for  the  most  vigorous  action  of 
pepsin  varies  with  the  form  of  proteids  employed.  For  example, 
pepsin  acts  best  on  fibrin  when  the  acidity  is  about  i  :  looo,  while 
coagulated  egg-albumen  is  digested  most  rapidly  when  the  acidity 
amounts  to  two  or  three  per  thousand  of  hydrochloric  acid. 

Test. — Three  test-tubes  or  small  wine  glasses  are  taken,  and  a 
small  thin  slice  of  boiled  egg-albumen  placed  in  each.  To  the  first 
is  added  three  c.c.  of  the  gastric  juice;  to  the  second,  three  c.c.  of 
the  gastric  juice  to  which  hydrochloric  acid  has  been  added  in  suffi- 
cient quantity  to  bring  the  acidity  to  two  or  three  per  thousand ;  the 
third  is  acidulated  as  in  number  two,  and  a  few  grains  of  pepsin 
added.  The  three  tubes  or  glasses  are  now  placed  in  the  incubator, 
at  a  temperature  of  40°  C,  and  allowed  to  remain  for  three  hours. 

If  at  the  end  of  this  time  all  three  tubes  show  digestion  by  the 
rounding-off  and  solution  of  the  egg-albumen,  the  specimen  con- 
tained pepsin;  if  number  two  and  three  only  show  digestion,  the 
contents  contained  pepsinogen  but  no  pepsin ;  while  if  only  the 
third  tube  or  glass  shows  traces  of  digestion,  the  specimen  con- 
tained neither  pepsin  nor  pepsinogen. 

Pepsinogen. — This  substance  is  supposed  to  be  secreted  by  the 
cells  of  the  gastric  mucosa,  and  to  be  changed  into  pepsin  by  the 
action  of  the  hydrochloric  acid  of  the  gastric  juice.  This  action 
has  been  differently  explained  by  various  experimenters,  the  most 
plausible  theory  being  that  a  combination  of  the  two  takes  place 
with  the  formation  of  pepsin — hydrochloric  acid. 

In  the  absence  of  hydrochloric  acid,  this  body,  pepsinogen,  may 
be  present  in  normal  amount,  and  require  only  the  addition  of  a 
sufficient  quantity  of  hydrochloric  acid  to  bring  the  gastric  juice  to 
a  normal  acidity  to  render  the  stomach  contents  active.  / 

In   the  absence  of  free   hydrochloric  acid,  we  may  test  for  thej 
presence  of  this  substance  by  acidulating  with  hydrochloric  acid,  as 


1 66  DETECTION    OF    RENNIN. 

in  number  two  of  the  pepsin  test,  adding  a  small  bit  of  boiled  egg- 
albumen  and  placing  in  the  thermostat  at  a  temperature  of  40°  C. 
for  three  hours,  at  the  end  of  this  time  noting  the  presence  or  ab- 
sence of  signs  of  digestion. 

Boas  following  out  the  observations  of  Briicke  ("  Vorlesungen 
iiber  Physiologie,"  p.  311,  1884.  Quantitative  determination  of 
pepsin,  etc.)  employs  a  comparative  test  which  in  doubtful  cases  may 
yield  valuable  information.  Properly  labeled  tubes  are  prepared, 
and  in  them  are  placed  measured  quantities  of  gastric  juice  diluted 
with  a  solution  of  hydrochloric  acid  of  the  normal  strength  of  the 
gastric  juice  (two  or  three  per  looo),  so  that  the  tubes  contain  the 
gastric  juice  in  dilutions  of  i  :  10  and  i  :  20.  To  each  tube  a  small 
flake  of  egg-white  or  fibrin  is  added  and  put  in  a  thermostat  at  the 
temperature  of  the  body.  From  the  amount  of  dilution  at  which 
digestion  ceases,  an  idea  may  be  gained  of  the  amount  of  pepsin  or 
pepsinogen  which  any  gastric  juice  contains.  For  comparison, 
similar  tubes  may  be  prepared  of  normal  gastric  juice,  and  the 
digestive  power  of  the  two  compared. 

Rennin  and  Rennin  Zymogen. — In  addition  to  pepsin,  the 
gastric  juice  also  contains  a  ferment,  or  its  zymogen,  whose  special 
property  appears  to  be  the  precipitation  of  casein  from  milk.  As 
in  the  transformation  of  pepsinogen  into  pepsin  hydrochloric  acid 
is  required,  so  rennin  zymogen  in  the  gastric  juice  is  not  trans- 
formed into  rennin  except  in  the  presence  of  hydrochloric  acid. 
Certain  neutral  salts  of  lime,  such  as  calcium  chlorid,  however, 
have  the  power  of  transforming  rennin  zymogen  into  rennin,  even 
in  neutral  or  slightly  alkaline  solutions. 

The  following  tests  for  the  presence  of  rennin  and  its  zymogen 
have  been  devised  by  Boas  : 

Rennin. — Five  c.c.  of  the  gastric  juice  are  exactly  neutralized 
with  a  decinormal  solution  of  caustic  soda,  five  c.c.  of  neutral  milk 
added,  and  the  mixture,  after  being  well  shaken,  is  placed  in  an 
incubator  at  the  body  temperature. 

If  rennin  is  present,  the  casein  will  form  a  firm  coagulum  in 
from  ten  to  fifteen  minutes. 

A  relative  quantitative  estimation  of  the  rennin  ferment  may  be 
performed  by  the  following  method : 

The  gastric  juice  is  accurately  neutralized  and  portions  of  this 
diluted  with  distilled  water,  in  known  proportions,  i  :  10,  i  :  20,  etc. 
To  five  c.c.  of  each  of  these  dilutions,  five  c.c.  of  neutral  milk  are 


TEST    FOR    RENNIN    ZYMOGEN.  167 

added,  and  the  tubes  placed  in  the  thermostat  at  the  body  tem- 
perature for  fifteen  minutes.  At  the  end  of  this  time  the  tubes 
are  removed  and  the  dilution  at  which  no  coagulation  takes  place 
is  noted.  In  stating  the  dilution,  note  must  be  taken  of  the  fluid 
added  in  neutralizing. 

Rennin  Zymogen. — Five  c.c.  of  the  gastric  juice  are  rendered 
faintly  alkaline  by  the  addition  of  a  decinormal  solution  of  caustic 
soda;  one  c.c.  of  a  one  per  cent,  solution  of  calcium  chlorid  and 
five  c  c.  of  neutral  milk  are  added.  The  tube  is  placed  in  the  ther- 
mostat, and  after  fifteen  minutes  should  show  a  firm  cake  of  casein 
if  rennin  zymogen  is  present. 

Quantitative. — The  gastric  juice  is  rendered  faintly  alkaline  by 
adding  a  decinormal  solution  of  caustic  soda  and  dilutions  pre- 
pared, I  :  !0,  I  :  20,  etc.,  estimating  in  the  dilution  the  amount  of 
fluid  added  in  alkalinizing.  Five  c.c.  of  each  of  these  dilutions 
are  placed  in  test-tubes  with  five  c.c.  of  neutral  milk  and  one  c.c.  of 
a  one  per  cent,  solution  of  calcium  chlorid.  These  are  placed  in 
a  thermostat  at  the  body  temperature,  and  at  the  end  of  fifteen 
minutes  the  dilution  at  which  the  enzyme  fails  to  act  is  noted. 
From  the  observations  of  Boas  and  others,  it  appears  that  the 
secretion  of  the  ferments  and  the  pro-enzymes  is  less  affected  by  the 
minor  disturbances  which  may  cause  a  temporary  arrest  of  the 
acid  secretion  of  the  stomach.  Decrease  in  the  activity  of  the 
ferments,  on  the  other  hand,  is  usually  the  result  of  some  organic 
change  in  the  gastric  mucosa. 

By  experiment  upon  normal  individuals  it  has  been  found  that 
rennin  is  active  in  dilutions  of  from  i  :  30  to  i  :  40,  and  rennin 
zymogen  in  dilutions  varying  from  i  :  100  to  i  :  150.  It  has  been 
found  that,  even  in  the  absence  of  free  hydrochloric  acid,  the  fer- 
ments may  be  active  up  to  the  limit  observed  in  normal  individuals, 
and  that  in  such  cases  the  condition  of  anacidity  was  a  temporary 
matter,  due  to  some  mental  or  circulatory  disturbance,  the  acid  re- 
appearing when  the  cause  of  the  disturbance  was  removed. 

On  the  other  hand,  in  cases  of  anacidity  in  which  the  rennin 
zymogen  was  active  only  in  the  stronger  dilutions,  i  :  5,  i  :  10, 
etc.,  the  anacidity  is  due  to  some  organic  change  in  the  gastric 
mucosa  from  which  recovery  is  usually  rare. 

It  will  be  seen  from  these  considerations  of  what  importance  a 
quantitative  investigation  of  the  gastric  ferments  is  from  the 
progno.stic  standpoint. 


l68  PRODUCTS    OF    PEPSIN    DIGESTION. 

Action  of  Pepsin  on  Proteids. — The  action  of  pepsin  upon 
proteids,  as  has  been  shown,  only  takes  place  in  an  acid  medium. 
The  action  is  a  very  complex  one  and  is  not  as  yet  fully  understood. 
The  first  observable  result  of  the  action  of  a  hydrochloric  acid  solu- 
tion of  pepsin  upon  a  coagulated  albumen,  such  as  egg-white,  is 
apparently  a  partially  mechanical  change.  The  egg-white  swells  up, 
its  edges  become  rounder,  and  it  becomes  clearer  and  more  glassy 
in  appearance.  The  egg-white  then  begins  to  dissolve,  as  is  shown 
by  the  presence  in  the  solution  of  a  substance  precipitated  by 
neutralization,  which  may  be  called  syntonin,  or  acid  albumen. 
This  action  takes  place  also  in  acid  solutions  to  which  pepsin  has 
not  been  added.  The  next  step  is  one  in  which  the  pepsin  plays 
an  important  part.  The  syntonin  or  acid  albumen  is  changed  first 
into  the  primary  albumoses,  proto-  and  hetero-albumose.  These 
undergo  further  change  and  become  deutero-albumoses,  and, 
finally,  peptones.  These  substances  may  be  distinguished  from 
each  other  by  the  following  reactions  : 

(a)  Native  albumens  may  be  removed  from  the  solution,  if 
present,  by  rendering  the  stomach  contents  faintly  acid,  if  not 
already  so,  and  boiling.  The  precipitate  will  consist  of  the  native 
proteids,  viz.,  albumen  and  globulin. 

(d)  The  solution  is  tarefuUy  neutralized  by  the  addition  of  a 
weak  caustic  soda  solution.  The  precipitate  will  consist  of  syntonin 
or  acid  albumen.  The  neutralization  must  be  exact,  as  the  precip- 
itate is  dissolved  by  an  excess  of  acid  or  alkali  to  form  acid-albu- 
men or  alkali-albumen,  respectively. 

[c)  The  filtrate  from  which  the  albumen  and  acid  albumen  has 
been  removed  is  now  saturated  with  magnesium  sulphate  and  fil- 
tered. The  precipitate,  which  consists  of  the  primary  albumoses, 
proto-  and  hetero-albumoses,  is  dissolved  in  water,  placed  in  a 
dialyzer,  and  the  salts  removed  by  dialysis.  As  hetero-albumose 
is  insoluble  in  pure  water,  it  is  precipitated  by  the  removal  of  the 
salts  as  in  a  dialyzer.  The  proto-albumose  remains  in  solution, 
as  it  is  soluble  in  water,  and  may  be  tested  for  by  acidulating 
with  nitric  acid  in  the  cold,  the  precipitate  redissolving  on  heating. 

(d)  Deutero-albumose,  or  secondary  albumose,  is  detected  in  the 
following  manner:  A  sufficient  quantity  of  the  gastric  juice  is  freed 
from  albumen  and  acid  albumen,  according  to  (a)  and  (d).  The 
filtrate  is  saturated  with  powdered  ammonium  sulphate  and  the 
precipitate  which  forms,  consisting  both   of  primary  and  secondary 


SEPARATION    OF    ALBUMOSES.  1 69 

albumoses,  is  filtered  off,  and  washed  thoroughly  with  a  saturated 
solution  of  ammonium  sulphate. 

The  precipitate  is  redissolved  in  the  least  amount  of  water  pos- 
sible, faintly  acidulated  with  acetic  acid  and  saturated  with  common 
salt,  which  precipitates  the  primary  albumoses,  leaving  the  deutero- 
albumose,  or  secondary  albumose,  in  solution.  After  filtration  the 
secondary  albumose  may  be  detected  by  saturating  again  with 
ammonium  sulphate  any  precipitate  which  may  form  consisting  of 
deutero-albumose.  It  may  be  detected  also  by  adding  a  consider- 
able amount  of  common  salt  to  its  solution  and  acidulating  with 
nitric  acid.  A  precipitate  will  form  in  the  presence  of  deutero- 
albumose,  redissolved  on  heating. 

[e)  Peptone  may  be  detected  by  precipitating  all  the  other  pro- 
teids  by  saturating  with  ammonium  sulphate  and  filtering.  The 
filtrate  contains  the  peptone,  which  may  be  tested  for  by  the  biuret 
reaction.  The  filtrate  is  treated  with  an  excess  of  caustic  alkali 
and  a  few  drops  of  a  very  dilute  solution  of  copper  sulphate.  If 
peptones  are  present  in  the  solution  a  pink  or  rose-red  color 
appears. 


CHAPTER    XIX. 

GASTROSCOPY. 

The  first  one  to  use  a  gastroscope  was  Mikulicz  ("  Ueber  Gas- 
troskopie  u.  Oesophagoskopie,"  M'^ien.  med.  Presse,  i88i,  No.  43  ; 
also  IVien.  med.  WocJienschr.,  1883,  Nos.  23  and  24).  The  instru- 
ment used  was  made  by  Leiter,  of  Wien,  and  was  curved  at  an  ob- 
tuse angle.  The  following  account  of  the  technic  and  value  of  the 
method  is  quoted  from  Rosenheim  [loc.  cit.) : 

"  Gastroscopy  is  founded  on  the  fact  discovered  by  this  author, 
that  in  the  majority  of  cases  (80  per  cent.)  it  is  possible  to  intro- 
duce, without  special  difficulty,  a  straight,  rigid  tube,  12  mm.  in 
diameter,  the  patient  having  first  been  placed  in  the  dorsal  posi- 
tion. It  is  possible  to  introduce  such  a  tube  far  into  the  stomach, 
often  as  far  as  the  navel,  and  "eventually  below  the  same.  The 
establishment  of  this  fact  first  furnished  him  with  a  foundation 
on  which  gastroscopy  could  be  developed,  after  he  had  come  to 
the  conclusion  that  an  optical  apparatus,  to  be  suitable  for  the 
stomach,  must  be  straight  as  in  the  cystoscope  (Rosenheim, 
'  Gastroskopie,'  Berlin,  klin.  Wochenschr.,  1896,  No.  13). 

"  Apart  from  complications  that  are  due  to  tumors,  exudations, 
enlargement  of  the  liver,  etc.  (that  is,  to  the  pathological-anatomical 
conditions),  apart  also  from  congenital  anomalies  (abnormally  con- 
torted course  of  the  esophagus  or  abnormal  contraction),  two  facts 
are  to  be  considered  in  the  light  of  an  impediment  to  a  successful 
probing  by  means  of  introducing  a  rigid  tube  into  the  stomach  :  in 
the  first  place,  the  bend  to  the  left,  or  spiral  twist,  which  the 
esophagus  shows  so  frequently  in  its  subphrenic  part ;  and,  secondly, 
the  occurrence  of  spasm  at  the  lower  physiological  contraction  of 
the  organ.  With  continued  practice  it  becomes  apparent  that  the 
anatomical  obstruction,  caused  by  the  change  in  the  direction  of 
the  esophagus,  may  usually  be  overcome  if  the  instrument  is  intro- 
duced from  the  right  angle  of  the  mouth,  preferably  while  the 
head  is  turned  slightly  to  the  right,  laterally. 

"  The   obstruction   before   the  cardia,   caused   by   spasm  of  the 

170 


DESCRIPTION    OF    GASTROSCOPE. 


171 


muscles  of  the    esophagus,  can   not  be  eliminated  mechanically; 
here  the  manner  of  introducing  the  tube  ^ 

makes  no   difference,  and   soothing   the  ^       B  l^ 

patient,  persistence,  and  adaptation  can 
alone  lead  to  the  desired  result.  Local 
anesthesia  is  useless.  How  much  the 
occurrence  of  the  spasm  is  due  to  the 
psychic  condition  of  the  patient,  was 
shown  by  numerous  observations  with 
invalids,  particularly  neurasthenic  per- 
sons, who  were  timid  and  restive  when 
the  probe  was  first  introduced,  and  with 
whom  it  was  impossible  to  penetrate  to 
the  stomach  ;  while  later,  after  they  had 
become  familiar  with  the  proceeding, 
this  was  easily  accomplished.  It  is 
necessary  to  keep  in  mind,  also,  that  the 
spasm  appears  more  frequently  with 
persons  who  are  suffering  with  an  ulcer 
or  carcinoma  near  the  cardia." 

Description  of  the  Instrument. — 
(See  Fig.  24.)  The  gastroscope  is  a 
straight  metal  instrument,  68  cm.  in 
length,  12  mm.  in  diameter,  consisting 
of  three  concentric  systems  of  tubes, 
and  terminating  in  a  larger  head-piece 
for  the  different  conduits.  The  inner 
tube  (i)  forms  an  optical  apparatus, 
the  ocular  of  which  is  situated  at  0, 
and  a  rectangular  prism,  P,  is  located 
in  front  of  its  objective  lenses.  The 
visual  angle  of  the  telescope  (otherwise 
constructed  according  to  the  principle 
which  has  been  approved  in  the  cysto- 
scope,  viz.,  as  a  terrestrial  telescope) 
amounts  to  60°,  so  that  it  is  possible  to 
inspect  an  area  five  cm.  in  diameter  at  a 
distance  of  five  cm.  from  the  object. 
The  center  of  the  portion  in  view  lies 
vertically  over  the  small  side  (cathetus) 


1/2  GASTROSCOPY. 

of  the  rectangular  prism  which  receives  the  image.  In  order  to 
inspect  a  surface  the  center  of  which  does  not  He  at  right  angles  over 
the  cathetus,  the  rectangular  prism  may  be  replaced  by  an  acute 
angular  prism  ;  by  this  means  those  surfaces  also  can  be  examined 
that  are  situated  above,  which  can  be  only  partially  viewed  by 
means  of  a  rectangular  prism.  The  absolute  necessity  of  inspecting 
parts  of  the  stomach  which  appear  at  varying  heights — for  instance, 
the  region  of  the  pylorus — explains  this  arrangement. 

The  optical  apparatus  is  inclosed  by  a  tube  (3)  that  is  closed 
at  the  lower  end  by  a  head-piece,  A,  carrying  a  tip  of  rubber,  G. 
Just  above  the  tip  there  is  an  aperture,  /%  which  is  closed  by  a 
glass  window,  behind  which  there  is  situated  an  incandescent  lamp, 
as  shown  in  .S".  At  the  upper  and  lower  ends  of  the  lamp  the 
metal  contacts  that  conduct  the  current  are  fastened.  Above  the 
window  there  is  a  second  aperture,  B,  in  which  the  prism  is  adjusted, 
and  inside  of  which  it  may  even  be  moved  up  or  down.  In  the 
tube  (3)  there  are  four  canals  separated  from  one  another.  Two 
of  these  canals,  which  end  at  C  and  D,  serve  to  conduct  water 
through  the  instrument  and  around  the  lamp,  to  prevent  excessive 
heating  of  the  tubes  caused  by  the  incandescent  lamp.  The  third 
canal  is  used  to  receive  the  wires  that  conduct  the  current  to  the 
lamp;  while  the  fourth  canal,  which  begins  at  /,  and  opens  at  the 
lower  end  of  the  instrument  behind  the  window,  F,  is  used  to 
introduce  air,  which  must  be  pumped  into  the  stomach,  by  means 
of  a  blast,  to  distend  its  walls.  Toward  the  top,  the  thin  tube 
terminates  in  a  larger  head-piece  that  establishes  the  connection 
of  the  canals  with  the  different  conduits  for  water,  air,  and  elec- 
tricity. 

Fig.  24  (i)  shows  the  sliding  tube,  a  tube  with  a  centimeter  scale, 
that  can  be  shoved  over  the  instrument  (3)  and  easily  revolved 
on  the  same.  It  has  an  aperture  at  £  corresponding  to  the 
aperture  B,  and,  by  being  turned  180  degrees,  it  serves  to  cover  this 
aperture,  as  well  as  the  prism  lying  behind  the  same,  so  as  to 
prevent  the  optical  apparatus  from  being  soiled  by  mucus  while 
the  instrument  is  being  introduced.  If  the  external  tube  is  so 
adjusted  that  the  aperture  B  is  closed,  and  if,  to  further  protect  the 
optical  apparatus,  the  latter  is  turned  180  degrees  so  that  the 
exposed  surface  of  the  prism  faces  the  side  of  the  tube,  then  the 
prism  enjoys  a  double  protection,  and  in  consequence  the  instru- 
ment can  not  be  soiled  while  beinw  introduced.     Small  metal  knobs 


DESCRIPTION    OF    GASTROSCOPE.  I73 

are  attached  to  the  top  of  all  three  tubes,  to  enable  us  to  control 
from  the  outside  their  position  in  the  stomach  ;  when  these  stand 
in  a  straight  line,  the  observer  knows  that  the  prism  is  not  covered 
by  the  revolving  tube,  but  faces  the  cavity  of  the  stomach  through 
the  aperture.  The  electric  current  +  and  —  is  introduced  at 
the  points  of  contact  by  means  of  a  movable  cable  that  is  equipped 
with  an  interrupter.  The  intensity  of  the  electric  current  is  16 
volts.  In  conducting  water  through  the  apparatus,  a  stand  carry- 
ing an  irrigator  is  used.  The  two  rubber  tubes  conduct  the 
water  through  the  instrument.  By  means  of  a  cock  the  flow  of 
the  water  can  be  interrupted.  Another  tube  carries  the  water 
that  has  passed  through  the  instrument  into  the  water-bucket. 
To  cool  the  instrument  it  is  advisable  to  use,  not  cold  water,  but 
water  of  about  40°  C,  in  order  that  the  lenses  of  the  optical 
apparatus  and  the  surfaces  of  the  prism  may  not  be  covered 
with  a  film  of  moisture  caused  by  sudden  condensation.  The 
stand  carries  the  accumulator  (storage  battery)  used  to  furnish 
the  electricity;  this  is  supplied  with  a  rheostat  for  regulating  the 
current,  and  also  with  an  interrupter. 

It  is  absolutely  necessary  in  every  case  to  convince  ourselves, 
before  carrying  out  the  gastroscopic  investigation,  that  the  way 
from  the  teeth,  as  far  as  the  great  curvature,  is  really  unobstructed, 
and  no  special  difficulties  are  offered  to  the  passage  of  a  straight 
rigid  tube  while  the  patient  occupies  the  dorsal  position.  This  test 
should  never  be  neglected;  at  the  same  time  it  should  be  carried 
out  with  the  greatest  caution. 

Rosenheim  employs  for  this  purpose  a  hollow  steel  probe  70  cm. 
long,  and  having  the  diameter  of  the  gastroscope  (12  mm.),  or  a 
smaller  one,  ending  likewise  below  in  a  rubber  appendage,  in  the 
side  of  which  there  is  a  small  aperture  provided  with  a  blast;  the 
parts  can  be  screwed  off  to  facilitate  cleansing  ;  a  centimeter  scale 
is  engraved  on  the  sides.  This  probe  is  introduced  in  the  dorsal 
position,  preferably  from  the  right  corner  of  the  mouth;  after 
measurements  along  the  back  have  been  made  to  determine  the 
distance  of  the  cardia  from  the  teeth,  and  after  having  applied 
a  four  per  cent,  solution  of  cocaine  to  the  pharynx,  the  patient  is 
directed  to  breathe  quietly  and  deeply,  and  to  lift  his  right  hand 
on  feeling  a  pain  in  the  region  of  the  stomach  or  above  the  same. 
If  the  patient  shows  pain,  the  procedure  must  cease  at  once.     If 


1/4  PROCEDURE    OF    GASTROSCOPY. 

resistance  is  felt,  a  moment  of  rest  intervenes,  or  eventually  the 
instrument  is  retracted  a  little,  only  to  try  again  whether  the 
resistance  yields  under  gentle  pressure,  the  reaction  on  the  part  of 
the  patient  meanwhile  determining  the  degree  of  energy  that  is  to 
be  employed  in  this  manipulation.  The  absolute  law  in  probing  is 
to  avoid  all  strong  pressure,  otherwise  lesions  of  the  membrane, 
even  perforation  of  the  esophagus  or  stomach,  may  be  the  con- 
sequence. After  the  diaphragm  has  been  passed,  air  is  pumped 
into  the  stomach  and  we  determine  how  far  the  instrument  is  able 
to  penetrate  into  the  inflated  organ. 

The  correct  guiding  of  the  instrument  from  the  right  corner  of 
the  mouth  plays  an  important  part  in  the  success  of  introducing 
the  instrument  in  the  majority  of  cases. 

If  we  wish  to  get  our  bearings  and  inform  ourselves  by  means 
of  the  telescope  about  the  vast  cavity  of  the  stomach,  it  is  prefera- 
ble to  start  from  the  normal  position  just  described:  The  point 
of  the  instrument  far  down  at  the  great  curvature,  the  window 
turned  to  the  front.  In  this  position  the  front  wall  of  the  stomach 
approaches  the  eye  closely,  within  from  two  to  three  cm.,  so  that  we 
see  it  magnified.  A  hasty  glance  suffices  to  recognize  the  condition 
of  the  mucous  membrane  here,  and  we  then  immediately  change 
the  position  of  the  instrument  by  revolving  it  slowly  to  the  right 
so  that  the  prism  faces  the  pylorus.  This  part  of  the  stomach  and 
the  adjoining  portion  of  the  small  curvature  varies  in  its  distance 
from  the  prism  in  various  cases.  The  distance  is  from  6  to  12  cm., 
and  the  image  which  we  receive  of  this  section  is  therefore  usually 
somewhat  reduced  in  size  (to  about  }4)'  We  now  are  examining  a 
part  of  the  organ  that,  from  a  practical  point  of  view,  is  perhaps  the 
most  important,  since  ulcers  and  cancers  are  so  frequently  located 
there.  We  exert  ourselves  now,  starting  from  the  opening  of  the 
pylorus,  to  investigate  systematically  the  whole  hollow  cone,  situ- 
ated to  the  right.  This  part  does  not  escape  us  as  a  rule,  if  we 
move  the  tube  gradually  from  the  great  curvature  upward  while 
revolving  the  apparatus  generally  in  both  directions.  After  we 
have  found  the  orifice  of  the  stomach,  as  a  fixed  point,  it  is  not 
difificult  to  espy  from  the  same  the  neighboring  section  of  the 
small  curvature,  at  least,  and  something  of  the  rear  wall.  The  higher 
the  portio  pylorica  lies  behind  the  liver,  the  more  it  (as  is  normal) 
bends  away  to  the  rear  on  the  right,  the  more  difficult  it  is  to 
inspect,  while  a  low  position   greatly  facilitates  our  investigation. 


THE    ESOPHAGOSCOPE.  1 75 

In  the  former  case  (for  which  we  may  be  somewhat  prepared  by 
the  preceding  inflation  of  the  stomach)  the  optical  apparatus  pro- 
vided with  an  acute-angled  prism  is  recommended.  It  is  possible 
to  recognize  how  different  the  distance  is  between  the  prism  and 
the  pylorus  during  the  normal  position  of  this  segment  of  the 
org-an   and    durin?   dislocation  of  the  same.     In  the  former  case 


Fig.  25. 
I.  Esophagoscope.     2.  Obturator.     3.  Esophageal  forceps.     4.  Esophageal  applicator. — {RosenJieitiz.*) 

the  distance  is  more  considerable;  we  must  withdraw  the  instru- 
ment further,  to  bring  at  least  a  part  of  the  portio  pylorica  within 
the    angle    of  the    prism ;    and    if    the    point    of    the    instrument 


*  Our  thanks  are  due  to  Prof.  Theod.  Rosenheim  (Berlin)  for  presentation  of  these 
illustrations. 


176  GASTROSCOPY. 

diverges  a  little  further  to  the  left  from  the  vertebral  column, 
this  approach  to  the  cardia  avails  nothing;  under  all  circumstances 
we  receive  only  an  image  of  the  part  beneath  the  orifice  of  the 
stomach.  During  these  manipulations  we  are  in  danger  of  being 
surprised  by  an  obscuring  of  the  field  of  vision,  since  we  are 
compelled  to  approach  closely  the  descending  part  of  the  small 
curvature  adjoining  the  cardia.  These  disturbances  are  avoided 
if  we  take  a  view  of  the  pyloric  portion  from  a  deeper  point, 
a  thing  which  can  be  conveniently  effected  by  the  employment 
of  an  acute-angled  prism  in  the  apparatus  ;  the  center  of  the 
circle,  which  we  then  survey,  no  longer  stands  perpendicularly 
over  the  prism.  We  no  longer  receive  the  image  from  a  region 
at  the  same  level  with  the  prism,  but  from  one  a  little  higher. 

If  the  pyloric  portion  is  dislocated  to  the  lower  margin  of  the 
liver,  or  deeper,  the  rectangular  prism  opposite  the  same  can  easily 
be  adjusted  without  needing  a  correction. 

After  inspecting  the  pyloric  portion  we  approach  the  great 
curvature  with  the  point  of  the  gastroscope,  and  turn  the  instru- 
ment to  the  left  by  180°  ;  while  slowly  withdrawing  the  instrument, 
we  next  inspect  the  part  of  the  fundus  and  cardiac  portion  that 
belong  to  the  left  half  of  the  body.  The  investigation  is  now  com- 
pleted; the  illumination  is  discontinued,  the  revolving  tube  is 
pushed  in  front  of  the  window,  the  blast  is  removed  in  order  that 
the  gases  may  quickly  escape ;  only  after  this  the  instrument  is 
withdrawn.  Rosenheim  has  devised  a  gastroscope  more  recently 
in  which  the  stream  of  water  for  the  cooling  of  the  electric  lamp  is 
dispensed  with  ;  the  lamp  is  only  flashed  now  and  then,  and  not 
kept  incandescent  continuously.  The  latter  instrument  is  thinner 
and  only  ten  mm.  in  diameter. 

Conclusion. — (i)  Not  all  parts  of  the  interior  of  the  stomach 
can  be  inspected.  Portions  of  the  greater  curvature — ^of  the  pos- 
terior wall,  the  immediate  neighborhood  of  the  cardia,  are  not 
visible.     It  can  not  be  practised  on  all  individuals. 

(2)  All  suspected  cases  of  ulcer  must  be  excluded  if  recent 
pain  and  hemorrhages  have  occurred.  Ulcers  at  pylorus  are  less 
liable  to  be  injured  than  those  near  the  cardia. 

(3)  Rosenheim  suggests  that  gastroscopy  may  be  employed  for 
the  early  diagnosis  of  carcinoma  and  its  differentiation  from  ulcer. 
He  admits  that  it  is  an  inconvenient  procedure. 


PART  SECOND. 

THERAPY   AND   MATERIA   MEDICA    OF  STOMACH 

DISEASES. 


CHAPTER  1. 

THE     PRINCIPLES    OF    DIETETIC     TREATMENT    OF 
GASTRIC    DISEASES. 

In  the  chapter  on  the  physiology  of  digestion  we  have  briefly 
considered  the  various  food-substances,  their  nutritious  and  innu- 
tritious  constituents,  the  amounts  of  each  requisite  to  maintain  a 
healthy  organism,  and  their  caloric  values,  etc.  It  is  one  of  the 
far-reaching  deserts  of  the  great  Father  of  medicine  to  have  first 
methodically  developed  dietetics  for  the  sick  as  a  special  discipline 
and  an  integral  part  of  therapy. 

In  his  classical  dissertation  on  the  conduct  of  febrile  diseases 
(Hippocrates,  "  De  victus  ratione  in  morbis  acutis  "),  in  his  aphor- 
isms, and  in  many  other  treatises,  he  emphasizes  the  great  impor- 
tance of  careful  regulation  of  nutrition  for  patients.  His  principles, 
based  upon  analytical  experience,  are  stated  with  unsurpassable 
precision.  His  dietetics  are  free  from  speculation,  and  regard  the 
nature  and  stage  of  the  disease,  the  constitution,  age,  and  habits  of 
the  patient;  above  all,  they  show  what  is  in  our  days  termed  an 
individualizing  principle.  It  would  seem  probable  that  a  therapeutic 
aid  that  had  been  logically  considered  at  the  very  dawn  of  medical 
knowledge,  and  by  such  an  able  mind,  would  at  the  present  time  be 
one  of  the  most  highly  developed  in  medicine,  particularly  when 
one  reflects  upon  the  declaration  of  Bonders  ("  Die  Nahrungsstoffe 
des  Menschen,"  Crefeld,  1853):  "  Whoever  works  at  the  develop- 
ment of  our  knowledge  on  food-substances  is  working  on  a  broad 
basis  for  the  development  of  mankind."  Fortunately  for  us,  many 
bright  intellects  have  already  applied  themselves  to  this  work,  and 
our  knowledge  has  been  enriched  by  treasures  of  valuable  informa- 

177 


1/8  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

tion.  But  the  well-advised  special  student  can  not  fail  to  recognize 
that  we  have  only  entered  a  vast  territory,  and  that  the  greater  part 
of  it  remains  to  be  explored.  Even  the  small  portion  which  by 
hard  toiling  is  clearly  our  own,  is,  we  regret  to  say,  far  from  being 
the  common  property  of  the  profession,  at  least  it  does  not  seem 
to  realize  that  a  logical  and  individualizing  diet  is  a  more  potent 
therapeutic  factor  than  medicine. 

The  results  so  far  obtained  show  great  domains  of  research  and 
inquiry  yet  to  be  explored  for  truth  bearing  on  dietetics.  And 
many  of  our  present  results  demand  reconsideration  for  correct 
interpretation.  Various  eminently  fitted  observers  disagree  on  vital 
dietetic  questions,  because  the  special  point  of  view  from  which 
each  one's  research  ("  Fragestellung ")  was  undertaken  was  not 
identical,  sometimes  not  defined  with  precision.  Sometimes  the 
intricacy  of  the  question  to  be  solved  did  not  permit  of  direct 
methods  of  investigation,  and  indirect  methods  had  to  be  em- 
ployed. 

The  scales  of  digestibility  of  various  foods,  as  devised  by  Leube 
and  Penzoldt,  for  instance,  were  arrived  at  by  determination  of  the 
time  which  the  stomach  required  to  discharge  these  foods  into  the 
duodenum.  Evidently  the  term  digestibility  means  the  rate  of 
solution  of  the  various  food-substances  by  the  constituents  of  the 
gastric  juice,  or  of  the  intestinal  juices,  as  the  case  may  be.  Diges- 
tibility, therefore,  has  reference  mostly  to  secretion,  but  the  rate  of 
the  gastric  expulsion  of  chyme  is  a  problem  of  motility. 

To  be  of  easy  digestibility  food-substances  must — 

(i)  Offer  only  a  slight  resistance  to  the  digestive  juices  ;  z".  £".,  they 
must  be  of  easy  solubility. 

(2)  They  must  not  impede  nor  accelerate  peristalsis. 

(3)  They  must  not  excessively  irritate  the  digestive  organs, 
either  mechanically  or  chemically. 

(4)  They  must  not  increase  the  processes  of  fermentation  or 
putrefaction. 

(5)  The  greater  portions  of  the  substance  must  be  absorbable 
either  in  the  stomach  or  intestines. 

To  say  that  veal  in  amounts  of  100  gm.  leaves  the  stomach  in 
one  to  two  hours  does  not  imply  that  it  is  digestible,  for  the  same 
may  be  said  of  sawdust  (from  actual  experiment  of  a  colleague,  made 
upon  himself).  By  our  method  of  duodenal  intubation,  we  suc- 
ceeded in  regaining  from  the  duodenum  56.4  per  cent,  of  a  weighed 


CRITERION    OF    DIGESTIBILITY.  1/9 

amount  of  ingested  veal  two  hours  and  fifteen  minutes  after  it  had 
been  eaten.  The  veal  was  weighed  and  was  easily  recognizable; 
besides,  nothing  else  had  been  eaten  at  the  time.  The  celerity 
with  which  a  food  disappears  from  the  stomach  is  not  so  much  an 
indication  of  its  digestibility  as  it  is  of  the  gastric  motor  power. 

A  more  correct  way  to  determine  the  digestibility  of  various 
foods — one  which  we  have  systematically  experimented  with  on  a 
number  of  volunteers  from  our  classes  who  had  a  normal  digestion 
— is  to  find  out  how  much  by  weight  of  a  known  amount  of  in- 
gested food  is  converted  into  peptone  or  dextrose,  as  the  case  may 
be,  in  a  given  time, — for  instance,  one  hour  or  thirty  minutes. 

In  a  large  number  of  these  experiments  we  aspirated  some  of  the 
weighed  test-meals  from  the  duodenum  (method  of  the  author, 
Boas'  Archives  for  Digestive  Diseases,  vol.  ii).  For  approximately 
accurate  results  it  is  sufficient  to  weigh  the  insoluble  residue 
of  the  particular  food  that  is  drawn  out  of  the  stomach.  It  is 
necessary  to  have  those  experiments  which  are  to  serve  as  crucial 
tests  of  digestibility  made  with  comparatively  pure  proteids,  such  as 
meat  and  egg,  and  pure  carbohydrates,  such  as  rice.  The  amount 
of  water  used  in  the  cooking  and  the  amount  ingested  must  be 
known,  and  can  be  found  out  by  evaporating  control  samples  to 
dryness. 

It  may  thus  be  learned  how  much  proteid  is  rendered  soluble  by 
the  pepsin  hydrochloric  acid,  how  much  casein  is  digested,  or  how 
much  of  starch  is  converted  into  dextrose  in  the  fifteen  to  forty-five 
minutes,  or  any  desired  period  during  which  the  particular  ferments 
are  permitted  to  act.  The  results  can  naturally  not  be  absolutely 
correct,  but  only  relatively  so  ;  at  least,  they  are  as  correct  as  the 
conditions  of  the  experiment  will  allow  the  results  of  Leube  and 
Penzoldt  to  be. 

The  absolute  amount  of  food  need  not  be  regained  ;  all  that  is 
required  for  a  comparative  study  is  to  learn  in  a  given  sample,  say 
30  c.c,  the  proportion  of  soluble  and  insoluble  chyme.  Dextrose 
present  can  be  determined  by  titration,  as  we  have  shown  else- 
where; and  from  the  reactions  of  the  various  transition  products 
from  proteid  to  peptone  the  amount  of  the  latter  can  also  be 
approximately  known,  particularly  if  the  amount  of  solid  residue 
of  proteid  that  can  be  regained  is  learned  first. 

It  is  an  interesting  fact  that  the  results  of  these  tests  of  digesti- 
bility performed  directly  on  the  normal  stomach  can  be  confirmed 


l80  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

by  control  analysis,  made  with  animals  (making  allowance  for  the 
increased  secretion  of  HCl  in  dogs),  and  b}*  anah'sis  made  with 
artificial  digestive  mixtures  in  the  incubator.  In  the  chapter  on 
digestion  by  pepsin  it  has  been  explained  why  the  exact  gastric 
digestion  can  not  be  imitated  in  a  test-tube,  mainly  because  the 
formation  of  peptone  remains  at  a  certain  percentage  by  the 
absorption  of  peptones  over  that  amount.  As  soon  as  the  amount 
of  peptone  exceeds  a  certain  percentage,  it  retards,  inhibits,  and 
may  even  suspend  proteolysis;  besides,  the  stomach  attempts  to 
maintain  a  fairly  constant  degree  of  concentration  of  contents,  by 
removal  of  chyme  into  the  duodenum. 

Notwithstanding  all  these  differences,  test-tube  or  artificial 
digestion  experiments  are  very  valuable  for  comparative  studies  in 
digestibility,  particularly  when  deductions  are  made  in  combination 
with  test-meals  on  the  normal  and  diseased  human  stomach.  In 
the  stomach,  we  must  bear  in  mind,  there  is  a  carbohydrate  and  a 
proteid  digestion  ;  we  can  rarely  give  food  exclusively  from  the 
standpoint  of  gastric  digestion,  as  Leube  and  Penzoldt's  tables 
show  that  the  greater  portion  of  the  digestive  work  is  executed  in 
the  intestine. 

Our  results,  so  far  as  we  can  judge  at  present,  agree  with  the 
main  ones  of  these  observers.  Leube  studied  the  duration  of  reten- 
tion of  various  foods  in  the  stomach  of  diseased  patients,  and 
Penzoldt  in  the  stomach  of  healthy  individuals  before  they  were 
expelled  into  the  duodenum.  We  have  confirmed  their  principles 
by  experiments,  ascertaining  the  amounts  of  proteid  and  carbo- 
hydrates converted  into  a  soluble  form  in  a  given  time  in  normal 
and  pathological  stomachs.  These  experiments  were  supported  by 
tests  made  with  artificial  digestive  mixtures,  and  on  dogs. 

The  explanation  of  the  agreement  of  these  various  methods  of 
testing  digestibility  is  probably  the  fact  that  food-substances  which 
are  most  rapidly  and  thoroughly  converted  into  a  soluble  form, 
are  also  most  easily  expelled  into  the  intestines.  Easily  soluble 
proteids,  though  solid,  are  readily  converted  into  a  liquid,  or  at 
least  semi-solid,  form  in  which  they  are  readily  propelled  onward. 
Proteid  soluble  with  difficulty  is  retained  longer,  because  the 
pre-antral  sphincter  has,  to  a  degree,  a  selective  action,  and 
w-ill  not  readily  permit  the  passage  of  consistent  food.  The 
matters  of  solution  and  rate  of  propulsion  of  foods  are,  then,  the 
factors  which  are  intimately  correlated  and  largely  go  to  make  up 


ADAPTATION    OF    DIET.  l8l 

the  quality  of  digestibility.  The  definition  of  a  digestible  food, 
then,  is  one  that  makes  relatively  small  demands  upon  the  secretory 
and  motor  functions  of  the  stomach,  which  is  readily  absorbed  and 
produces  no  subjective  complaints  or  feeling  of  discomfort. 

From  a  pathological  point  of  view,  however,  the  conception  of 
digestibility  is  a  variable  one.  Foods  that  may  be  easily  digestible 
for  a  gastric-ulcer  patient  may  be  very  indigestible  for  a  cancer  case. 
Leube  and  Penzoldt's  method  of  estimating  gastric  digestibility 
by  the  rate  at  which  various  foods  are  expelled  into  the  duodenum, 
gives  a  relatively  correct  indication  for  the  sound  normal  organ, 
because  secretory  and  motor  functions  are  equally  taxed  as  they  go 
hand  in  hand. 

The  results  can  not  be  unconditionally  applied  to  abnormal  states 
where  one  or  the  other  function,  or  both,  are  disturbed,  sometimes  in 
opposite  directions,  secretion  increased,  motility  diminished,  or 
vice  versa.  There  are  conditions  in  which  gastric  digestion  is  com- 
pletely destroyed  and  must  be  replaced  by  the  intestinal  function. 
There  are  states  of  absolute  and  permanent  loss  of  gastric  secre- 
tion, in  which  the  propulsion  of  food  from  the  stomach  is  not 
delayed.  Now,  one  can  not  speak  of  gastric  digestibility  in  this 
case,  because  there  is  very  little,  if  any;  but  such  cases  may  have 
a  perfect  intestinal  digestion,  so  that  the  expressions  "  gastric  "  and 
"  intestinal  digestibility  "  are  plausible. 

The  diet  of  stomach  patients  must  be  varied  and  adapted  to  the 
conditions  of  the  secretion,  motility,  and  absorption  ;  but  the  diet 
must  also — and  this  is  generally  overlooked — be  adapted  to  the 
sensibility  of  the  stomach.  The  neuroses  of  sensation,  considered 
in  the  clinical  portion  of  this  work,  offer  a  fertile  field  of  work 
to  the  thoughtful  dietarian.  An  abnormally  increased  feeling  of 
hunger,  in  which  this  intensely  heightened  sensation  can  hardly  be 
appeased  by  food, — buliviia  and  akoria, — as  well  as  absence  of 
hunger,  in  which  the  appetite  is  very  readily  appeased,  can  in  many 
cases  be  successfully  treated  by  diet. 

By  treating  bulimia  dietetically,  we  do  not  mean  to  suggest 
unlimited  ingestion  of  food,  but  rather  a  painstaking  investigation  of 
the  cause,  which  may  be  an  unduly  large  stomach  or  convalescence 
from  infectious  disease  (typhoid,  diabetes).  We  do  not  class  the 
increased  desire  for  food  observed  in  men  performing  exceptional 
physical  work,  in  women  during  pregnancy  and  lactation,  as  well 
as  in  rapidly  growing  children,  as  bulimia.     This  augmentation  of 


1 82  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES, 

hunger  is  due  to  a  greater  requirement  of  food,  because  the  organ- 
ism has  greater  expenses  in  supplying  material  for  growth  or  energy. 
Many  forms,  perhaps  60  per  cent.,  of  bulimia  cases  are  due  either  to 
hyperesthesia,  hyperacidity,  or  hypermotility.  If  these  are  causes, 
the  treatment  given  under  these  diseases  should  be  administered 
(clinical  part).  The  meals  should  be  allowed  every  two  or  three 
hours,  and  consist  largely  of  such  proteids  as  hav^e  a  great  com- 
bining affinity  for  HCl.  These  are  given  under  Fleischer's  list  of 
the  HCl  binding  power  of  foods.  But  if  an  irritative  state  of  the 
glandular  layer  can  be  ascertained,  the  diet  should  be  largely 
amylaceous.  If  the  motility  be  exaggerated  with  the  hyperacidity, 
it  is  well  to  direct  the  patient  to  drink  frequently  of  cold  alkaline 
waters,  such  as  the  Saratoga  Vichy,  particularly  when  the  stomach 
is  empty. 

Anorexia,  in  its  severe  forms,  is  most  often  due  to  organic 
changes  in  the  gastric  walls.  In  the  nervous  forms  it  is  often 
benefited  by  a  course  of  forced  feeding  with  the  stomach-tube. 
Persistent  anorexia  in  highly  neuropathic  individuals  had,  in  fact, 
best  be  treated  this  way  as  soon  as  the  patients  positively  refuse 
food,  because  a  complete  cure  can  frequently  be  accomplished  by 
gavage  alone.  The  feeding  through  the  tube  has  a  moral  and 
educational  effect  not  to  be  underestimated.  In  our  experience  as 
physician  in  charge  of  Bay  View  Asylum,  many  cases  were  observed 
to  resume  taking  their  meals  with  good  appetite  as  soon  as  they 
became  convinced  that  forced  feeding  would  be  insisted  upon.  But 
aside  from  this  moral  effect  there  is  also  a  physiological  one  :  this 
consists  in  the  supplying  of  a  stimulant  to  the  stomach  in  the 
form  of  food.  Nourishment  is  the  proper  stimulant  to  secretion, 
and  if  it  is  wanting  for  a  long  time  the  functions  of  the  stomach 
soon  become  arrested,  and  with  them  the  appetite.  The  nutritive 
stimulant  to  the  gastric  mucosa  is  food  ;  it  causes  a  filling  of  the 
blood-  and  lymph-vessels,  thus  indirectly  bringing  about  a  better 
nutrition  of  the  histological  elements  of  the  mucosa  and  a  resumption 
of  HCl  formation  with  ferments,  which  in  anorexia  is,  as  a  rule,  sup- 
pressed. In  fact,  as  appetite  causes  eating  in  the  healthy,  so  eating 
will  cause  appetite  in  these  cases  of  anorexia.  In  mild  cases  of 
anorexia  a  sensation  of  hunger  is  frequently  started  up  by  salty 
and  "  piquante  "  articles,  such  as  caviar,  sardelles,  herrings,  etc.,  and 
at  the  same  time  small  doses  of  alcohol  with  bitter  tonics,  such  as  the 
Ansfostura  Bitters,  are  advisable.     Lavaee  with  solutions  of  chlorid 


EFFECT    OF    ABSORPTION    ON    SELECTION    OF    DIET.  1 83 

of  sodium  or  a  .04  per  thousand  HCl  is  most  effective.  The  most 
essential  condition  to  a  proper  dietetic  treatment  is,  of  course,  that 
the  patient  should  have  appetite.  A  great  point  is  gained  if  he  can 
be  made  to  take  food  with  pleasure.  For  the  management  of  those 
cases  with  anorexia  we  must  refer  to  the  article  on  this  subject. 

Sir  William  H.  Broadbent  iyBrit.  Med.  Jour.,  vol.  11,  1893,  p.  1268) 
says  :  "  In  all  cases  in  which  the  cause  has  been  overfeeding  or 
improper  food,  or  food  taken  at  a  wrong  time,  an  extremely  strict  and 
meager  diet  for  a  few  days  will  be  the  best  treatment.  No  advan- 
tage is  gained  from  a  low  diet  in  neurotic  cases. 

"The  object  we  set  before  ourselves  must  be,  not  to  level  down 
the  diet  to  the  digestive  capabilities  of  the  stomach,  but  to  level  7ip 
the  digestion  till  it  can  deal  efficiently  with  the  amount  of  food  for 
the  due  support  of  the  nervous  system.  No  hard  and  fast  rule 
can  be  laid  down."  Speaking  generally,  such  a  (neurotic)  patient 
will  digest  food  which  he  relishes  better,  even  if  it  have  the  repu- 
tation of  being  indigestible,  than  the  most  digestible  and  scientific- 
ally prepared  food  which  he  eats  by  order,  and  dislikes.  A  very 
common  experience  is  that  he  is  tempted  by  a  good  dinner,  eats 
largely  and  indiscriminately,  and  then,  instead  of  a  bad  night  and 
great  discomfort,  which  he  thinks  he  has  deserved,  he  sleeps  well 
and  feels  all  the  better  for  his  indiscretion. 

A  very  important  point  will  be  to  disabuse  the  patient's  mind  of 
the  idea  that  pain  after  meals  necessarily  indicates  that  the  food 
has  been  unsuitable.  One  day,  and  under  one  set  of  circumstances, 
anything  will  agree  ;  on  another  day,  under  different  circum.stances, 
nothing  is  digested.  Directions  must  be  given  not  to  eat  when 
exhausted  or  excited  or  anxious,  not  to  jump  from  meals  and  rush 
off  to  work  of  any  kind,  and  to  eat  very  slowly. 

The  state  of  the  gastric  absorption  has  to  be  considered  in  the 
selection  of  a  diet.  In  most  text-books  this  factor  of  dietetics  is 
entirely  neglected.  In  the  light  of  the  most  modern  knowledge  on 
absorption,  that  furnished  by  the  work  of  von  Mehring,  according 
to  which  it  is  almost  limited  to  cane-,  grape-,  and  milk-sugar, 
maltose,  dextrin,  alcohol,  and  peptone,  whilst  water  is  not  at  all 
absorbed  (see  Absorption,  p.  90),  it  is  not  at  once  evident  why  the 
state  of  absorption  should  be  considered  in  selecting  a  diet.  Von 
Mehring's  results,  however,  seem  to  point  the  way  in  selecting 
peptones,  maltose,  dextrin,  alcohol,  etc.,  where  we  must  depend 
on  rapid    diffusion    of  nutritious    material,   and    also  in   avoiding 


184  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

water,  or  foods  containing  water,  where  the  gastric  walls  are  weak, 
because  it  is  not  absorbed  and  overdistends  by  its  weight. 
Not  only  this,  but  simultaneously  with  resorption  a  more  or 
less  active  excretion  of  water  occurs  into  the  stomach.  The 
amount  of  this  e.Kcretion  of  water  increases  or  diminishes  with 
the  quantity  of  substances  resorbed  or  taken  up.  Certain  gastric 
diseases  connected  with  much  fermentation  are  supposed  to  be  in 
etiological  relation  with  tonic  muscular  spasms — forms  of  tetany  of 
gastric  origin.  Bouveret  and  Devic  ("  Rech.  clin.  et  experim.  sur 
la  tetanic  d'origine  gastrique,"  Revue  de  Med.,  1892,  xii,  p.  48) 
assert  that  alcohol  is  instrumental  in  favoring  the  formation  of  an 
intragastric  diffusable  toxin  in  dilations  and  hypersecretive  states, 
and  that  these  poisons  bring  about  the  spasms.  Fleiner  {loc.  cit.) 
and  Kussmaul  recommend  that  no  alcohol  in  any  form  be  given  in 
dilations  with  pyloric  stenosis,  where  naturally  the  absorption  of 
the  alcohol  must  be  very  much  retarded.  The  latter  authors  do 
not  accept  the  toxic  origin  of  the  spasms,  but  suggest  that  the 
alcohol  causes  a  tremendous  excretion  of  water  into  the  stomach, 
thus  robbing  the  organism  of  a  requisite  amount, — a  tetany,  there- 
fore, due  to  drying  of  muscles  and  nerves ;  both  views  are  merely 
hypotheses.  The  practical  deduction  is  that  where  the  absorption 
has  been   found  defective   by  tests,  alcohol  had  best  be  avoided. 

Boas  recommends  that  explicit  written  directions  be  given  to 
each  patient  after  the  diagnosis  has  been  made,  concerning — 

(i)  Exact  time  of  meals. 

(2)  An  exhaustive  account  of  articles  of  diet  and  luxury  that 
are  allowed. 

(3)  An  exact  statement  of  the  weights  and  measurements  of  the 
foods  and  beverages. 

(4)  Brief  instructions  on  the  preparation  of  the  food,  temperature 
of  drinks,  seasoning,  etc. 

(5)  Special  account  of  foods  that  are  forbidden. 

The  time  for  the  ingestion  of  food  is  an  essential  factor  in 
dietetics,  particularly  with  our  American  business  men,  with  whom 
it  is  a  common  practice  to  sacrifice  meal  hours  to  business.  The 
hours  for  meals  should  be  religiously  observed  by  gastric  sufferers, 
and  the  hours  for  stomach-rest  or  fasting  also.  Hyperacidity  and 
forms  of  nervous  dyspepsias  require  small  meals  frequently 
repeated ;  the  same  is  true  of  some  types  of  atonic  and  stenotic 
frastrectasias. 


PREPARATION    OF    FOOD.  1 85 

Other  stomach  diseases  require  long  pauses  of  rest  between  the 
meals,  and  it  is  not  always  possible  to  state  a  priori  how  much 
digestive  work  and  how  much  rest  any  particular  diseased  stomach 
may  require.  It  is  only  after  a  prolonged  study  of  the  various 
gastric  functions  that  the  physician  can  give  correct  instruction  in 
chronic  cases. 

There  is  much  need  for  enlarging  the  dietetic  menu  of  dys- 
peptics ;  nothing  should  be  forbidden,  except  there  are  actual  facts 
founded  on  experiment,  the  nature  of  the  disease,  or  the  idio- 
syncrasies of  the  case  proving  it  to  be  harmful.  Our  experience 
is  that  when  the  menu  is  too  limited  a  certain  disgust  for  the 
diet  eventually  becomes  manifest,  resulting  either  in  temporary 
anorexia  or  a  disregard  of  the  directions  and  indulgence  in  for- 
bidden foods. 

Directions  as  to  Preparations  of  the  Food  are  sometimes  neces- 
sary. Here  the  physician  must  be  able  to  indicate,  for  instance  in 
an-  or  subacidity  or  atrophic  gastritis,  that  the  meats  should  be  finely 
scraped  or  cut,  then  cooked  in  a  steam  broiler  with  a  liberal  season- 
ing of  pepper  and  salt.  In  hyperacidity,  gastroxynsis,  gastritis 
acida,  and  the  convalescence  from  gastric  ulcer,  all  seasoning  except 
a  little  salt  must  be  avoided ;  wherever  there  is  excess  of  HCl  the 
meats  should  also  be  finely  divided  before  cooking.  The  amounts 
of  paprika,  red  and  black  pepper,  mustard,  horse-radish,  lemon, 
vinegar,  and  ginger,  that  can  be  allowed  in  cases  of  absolute  sup- 
pression of  secretion  (as  these  materials  have  some  effect  in  stim- 
ulating secretion),  must  be  stated. 

The  preparation  of  soups  and  gravies,  the  amounts  and  kinds  of 
fats  and  sugars  to  be  used  in  the  cooking,  are  points  of  importance. 
For  a  more  detailed  account  of  these  indispensable  methods  and 
directions  for  preparations  of  food,  reference  must  be  had  to  works 
on  Dietetics, — vide  Oilman  Thompson,  Munk  and  Uffelmann,  Wiel 
(Tisch  fiir  Magenkranke),  Boas  ("  Diat  u.  Wegweiser  f.  Magen- 
kranke  "),  VVoltering  ("  Diatetisches  Handbuch  "),  Yeo,  Penzoldt 
(vol.  IV.  of  the  "  Handbuch  f.  speziel.  Therapie "),  Honigmann 
{Zeitschr.  f.  Krankenpflege,  1S94,  No.  8),  Wegele  ("  Diatetische 
Behandl.  d.  Magen-  u.  Darmkrankh.). 

The  Diet  as  Influenced  by  the  State  of  the  Secretion. — The 
anomalies  of  secretion  are:  (i)  Hyperacidity,  (2)  Sub-  and  Ana- 
cidity,  which  form  one  group  of  gastric  neuroses.  In  another 
group  we   may  classify  hypersecretion   (of  normal  gastric  iuice  in 


1 86  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

which  the  HCl  is  not  increased  or  diminished.)  This  is  the 
"  Magensaftfluss  "  of  Reichmann,  the  gastrosuccorrhea  chronica  or 
periodica,  of  which  Schreiber  holds  that  it  is  not  a  disease  siii 
generis.  We  class  the  so-called  "  gastroxynsis  "  of  Rossbach  with 
the  hypersecretions,  because  it  impresses  us  to  be  a  gastric  neuro- 
sis with  excessive  secretion  and  hemicrania,  and  is  hardly  entitled 
to  be  classed  as  a  distinct  and  separate  disease. 

As  far  as  diet  is  concerned,  the  hypersecretions  do  not 
exactly  coincide  with  the  hyperacidity  in  the  treatment.  For  the 
augmented  gastric  juice  in  the  super-  or  hypersecretions  may  be  a 
passive  act  on  part  of  the  glands, — their  activity  may  be  kept  up  by 
retained  food.  But  in  hyperacidity  the  excessively  high  percentage 
of  HCl  is  an  active  process,  an  irritative  state  of  the  mucosa  in 
which  it  responds  with  excessive  formation  of  acid  to  all  food 
stimuli.  In  the  hypersecretions  the  diet  should  be  selected  with 
regard  to  favoring  rapid  gastric  evacuation.  In  hyperacidity  there 
is  no  better  diet  than  rest.  These  are  states  in  which  there  is 
an  accelerated  digestion  of  albuminous  and  proteid  foods,  and  a 
retardation  of  carbohydrate  digestion,  which  is  caused  by  an  inhi- 
bition of  the  inverting  action  of  the  diastase  of  the  saliva,  the 
ptyalin  by  the  excessive  amount  of  HCl.  The  same  is  true  of  the 
pancreas  diastase.  Boas  has  shown  [loc.  cit.)  that  a  neutralization  of 
the  chyme  will  restore  the  diastatic  action,  but  we  have  assured 
ourselves  that  if  the  gastric  acidity  has  once  reached  0.3 
per  cent,  the  action  of  the  ptyalin  can  not  again  be  so  perfectly 
restored  by  neutralization  with  sodium  carbonate  as  it  was  before. 
In  other  words,  excessive  hyperacidity  permanently  damages  the 
ptyalin.  It  may  resume  some  inverting  action  after  neutralizing,  but 
it  is  not  equal  to  that  it  evinced  during  the  first  forty-five  minutes  of 
normal  gastric  digestion.  An  intensely  acid  gastric  juice  will  pro- 
duce a  deleterious  effect  on  the  bile  by  precipitating  from  it  a  sub- 
stance up  to  the  present  time  not  isolated,  by  which  it  effects  partial 
digestion  of  the  fats.  In  a  similar  way  the  secretion  of  the  pan- 
creas is  prevented  from  performing  its  work,  because  it  can  do  so 
only  in  an  alkaline  medium.  There  are  three  organic  diseases 
which  dietetically  come  under  this  group  of  excessive  acidity  or 
secretion;  these  are  ulcer,  gastritis  acida,  and  ulcus  carcinomato- 
sum.  Concerning  the  dietetic  treatment  of  hyperacidities,  uni- 
formity of  opinion  does  not  exist.  As  a  general  rule,  it  can  be 
stated  that  in  the  simple  forms  a  bland,  unirritating  diet,  which  at 


DIET    IX    HYPERACIDITY    AND    HYPERSECRETION.  1 8/ 

the  same  time  binds  as  much  hydrochloric  acid  as  possible,  should 
be  prescribed.  We  are  in  favor  of  a  diet  that  does  not  irritate  the 
mucosa  any  more  than  is  absolutely  necessary.  There  are  two 
indications:  (i)  An  etiological  one,  directed  to  the  condition  of 
the  mucosa  and  demanding  rest  for  the  irritative  state  present. 
(2)  A  symptomatic  one,  directed  to  neutralization  of  the  excess  of 
HCl  by  diet  having  the  greatest  HCl-binding  affinity.  These  two 
indications  are  to  some  extent  opposed  to  one  another.  The 
etiological  indication  necessitates  avoidance  of  albuminous  food, 
for  in  our  experience  proteid  and  albuminous  foods  produce  an 
increased  secretion  of  HCl.  The  second  or  symptomatic  indication 
calls  for  a  large  ingestion  of  albumen  to  combine  with  the  HCl. 
In  case  of  ulcer  the  food  must  be  the  least  irritating,  the  mildest 
that  our  menu  contains.  Not  the  total  quantity  of  acid  secreted 
constitutes  hyperacidity,  but  the  amount  secreted  in  excess  of  what 
is  required  for  combining  with  the  proteids.  For  instance,  a  case 
may  show  hyperacidity  after  a  simple  Ewald  test-breakfast  of  a 
roll  and  a  glass  of  water,  because  the  acid  secreted  has  nothing  to 
combine  with  and  remains  free,  whilst  the  same  case  may  show 
very  little  excess  or  normal  acidity  after  the  first  of  our  double 
test-meals,  as  employed  at  the  Maryland  General  Hospital,  consist- 
ing of  beefsteak,  eggs,  rice,  milk,  and  bread,  because  the  acid, 
in  this  instance,  at  once  enters  into  combination.  The  more 
abundant  secretion  of  HCl  is  more  completely  used  up  when  the 
meals  consist  of  a  preponderance  of  proteid  food  than  when  they 
consist  of  carbohydrates.  Therefore,  the  dietetics  of  these  cases, 
as  usually  recommended,  include  the  red  meats,  venison,  game, 
turkey,  eggs,  chocolate,  etc.,  liberally,  a  certain  limitation  of  car- 
bohydrates, and  the  alkaline  carbonated  waters.  In  hyperacidity 
and  supersecretion  spices  are  to  be  forbidden,  and  only  so  much 
salt  as  is  indispensable  to  make  the  food  palatable.  All  acids,  such 
as  vinegar  or  lemon-juice,  in  the  food  simph'  aggravate  the 
trouble. 

There  are  undoubtedly  different  kinds  of  hyperacidities.  We  feel 
justified  in  distinguishing  two  classes:  (i)  Those  in  which  there 
is  a  preponderance  of  nervous  symptoms  and  fragments  of  the 
mucosa  show  no  increase  in  the  number  of  gland-tubules  or  in  the 
oxyntic  or  acid  cells  •  these  cases  are,  then,  of  a  purely  neurotic 
type. 

(2)  Secondly,  those  in  which  there  is  an  increase  in  the  number 


1 88  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

of  gland-tubules  or  in  the  oxyntic  cells.  There  is  no  hard  and  fast 
line  to  separate  these  classes,  but  they  demand  somewhat  different 
treatment.  A  number  of  competent  observers  have  recommended 
an  exclusion  of  proteid  and  an  increase  of  the  carbohydrate  foods 
in  hyperacidity. 

For,  although  proteid  foods  combine  with  more  HCl  than  any 
other,  they  are  also  the  greatest  stimulants  to  the  secretion  of 
acid.  See  Dujardin-Beaumetz  ("  Traitement  des  maladies  de 
I'estomac  ")  and  von  Sohlern  {^Berlin,  klin.  IVochenschr.,  xc\,  Nos. 
20  and  21);  Fleiner  [Volkniann's  klin.  Vortr.,  No.  103);  Rummo 
{Terapia  cliii.,  1892,  Nos.  10,  ii,  12);  v.  Jaksch  {Zeitschr.  f.  klin. 
Med.,  Bd.  xvii,  1896.)  These  writers  argue  that  carbohydrate  food 
is  not  so  irritating  and  calls  forth  much  less  secretion  of  HCl. 
W.  Roux  ("  Entwicklungsmechanik  der  Organismen,"  1895)  states 
that  increased  activity  heightens  the  specific  force  of  the  organs, 
whilst  diminished  activity  lowers  it.  The  existence  of  the  cells  of 
the  organism  depends  upon  their  work  ;  those  that  work  most  are 
nourished  best  and  grow  strongest.  In  other  words,  the  elements 
in  any  tissue  that  are  incited  to  greatest  activity  and  function  will 
gain  supremacy  over  others  and  increase  in  strength  and  numbers. 
The  deductions  are  not  purely  theoretical,  for  not  only  do  we  find 
proliferation  of  acid  cells  in  h}-perchlorh\-dria  to  be  present  in  from 
50  to  75  per  cent,  of  the  cases,  but  in  animals  with  a  high  acidity 
of  HCl  (dog,  fox,  wolf,  etc.,  carnivora)  there  is  a  tremendous 
multiplication  of  acid  cells.  It  seems  logical,  therefore,  that  there 
are  cases  in  which  the  hyperacidity  may  in  the  long  run  be  kept 
up  by  a  proteid  diet,  although  for  the  time  being  this  diet  may 
render  the  acidity  less  by  combining  with  the  free  HCl.  Ex- 
perience teaches  that  the  most  annoying  symptoms,  the  gastralgia 
and  pyrosis,  are  promptly  relieved  by  the  proteid  diet,  and  we  shall 
endorse  the  latter  as  most  eminently  proper  in  selected  cases. 
When,  however,  the  symptoms  are  relieved  only  very  briefly,  par- 
ticularly when  the  ratio  of  the  ethereal  to  the  preformed  sulphates 
in  the  urine  is  found  to  become  very  high  under  a  rich  albuminous 
diet,  and  the  indican  increases,  we  advise  a  diet  rich  in  carbohy- 
drates and  fats.  See  Chas.  E.  Simon,  on  "  The  Relation  of  Indican 
to  Gastric  Diseases  "  [Am.  Jonr.  Med.  Sciences,  August,  1895).  This 
can  be  filled  by  all  breads  and  articles  made  from  flour,  rice,  peas, 
beans,  potatoes,  the  cereals,  oatmeal,  and  rich  milk  and  butter.  It 
is  true  that  in  some  forms  of  hyperacidity  these  substances  can  be 


HYPERACIDITY    TREATED    BY    AMYLACEOUS    DIET.  1 89 

found  sometimes  six  hours  after  they  are  ingested,  unchanged  in 
the  stomach  ;  here  the  motility  is  seriously  at  fault.  As  alkalies 
must  be  given  even  with  a  proteid  diet,  they  should,  in  case  the  food 
consists  largely  of  carbohydrates  and  fats,  be  given  immediately 
after  meals  and  combined  with  ptyalin  or  diastase  to  hasten  amylo- 
lysis.  It  is  frequently  observed,  that  the  amount  of  free  HCl  be- 
comes less  and  less,  and  the  alkalies  and  artificial  ferments  may  be 
dispensed  with  if  the  amylaceous  diet  is  persisted  in.  This  diet  we 
suggest  particularly  after  the  albuminous  diet  has  failed,  for  there 
are  cases  of  hyperacidity  which  are  undoubtedly  maintained  by  an 
exclusive  proteid  diet.  It  must  not  be  overlooked  that  such  a  thing 
as  a  pure  carbohydrate  diet  does  not  exist,  because  all  articles  of 
this  class  contain  protein,  and  some  very  considerable  quantities 
of  it;  peas,  beans,  and  lentils,  for  example,  contain  more  protein 
than  beef,  ham,  or  fish.  It  is  not  a  total  exclusion,  but  simply  a 
reduction  of  proteid  that  is  practically  recommended. 

All  cases  of  hyperacidity  require  a  certain  amount  of  carbohy- 
drates. It  is  a  matter  of  experience  that  proteid  diet  alone  will 
not  permanently  satisfy  their  cravings.  Flour  and  the  many  arti- 
cles prepared  from  it  are  not  readily  converted  into  dextrin  in  an 
excessively  acid  medium.  It  is  expedient,  therefore,  to  recommend 
dextrinized  flours,  such  as  Avenacia,  Maggi,  and  Kuffeke's  flour. 
The  American  product,  "  Horlick's  Food,"  is  a  flour  in  which  the 
wheat  starch  has  been  almost  entirely  converted  into  dextrin  by  malt 
diastase.  It  has  a  high  caloric  value,  and  its  price  is  sufficiently 
moderate  for  humbler  practice  when  artificial  flours  seem  indicated. 

Regarding  the  preparation  of  carbohydrates,  we  refer  to  the 
special  lists  given  in  the  text  under  the  various  diseases,  and  to 
Wegele's  "  Diatetische  Kiiche."  In  the  hyperacidity  of  ulcer,  the 
diet  must  be  of  the  least  irritating  quality,  and  the  coarse-fibered 
meats — beef,  mutton,  lamb,  veal,  venison — are  not  to  be  allowed, 
even  during  the  periods  of  convalescence,  and  when  they  are  finally 
conceded,  they  should  all  be  reduced  to  a  pulpy  (scraped)  form. 

In  sub-  or  anacidity,  when  the  motor  function  is  good,  the  prob- 
lem of  diet  is  not  so  complicated,  because  the  deficient  HCl  can 
be  supplied  if  it  is  found  necessary,  and  the  intactness  of  the  peris- 
talsis insures  a  good  intestinal  digestion.  As  the  motility  is  the 
only  safeguard  against  malnutrition,  great  care  should  be  taken  to 
avoid  injuring  it  by  overloading  the  organ.  Small  meals  frequently 
repeated  are  indicated,  consisting  of  very  tender  meat  (in  fine  sub- 


190  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

division),  soft,  tender  vegetables,  such  as  finely  chopped  spinach, 
cauliflower,  ends  of  asparagus,  puree  of  potatoes,  peas,  beans,  len- 
tils. The  fats,  which  are  best  given  in  form  of  rich  cream  and  good 
butter,  have  a  high  caloric  value.  They  must  be  forbidden  as  soon 
as  it  is  discovered  that  they  cause  gastric  irritation  by  formation  of 
fatty  acids.  The  diet  must  vary  according  to  the  cause  of  the  sub- 
or  anacidity.  If  it  can  be  ascertained  that  there  is  no  injury  of  the 
glandular  apparatus,  but  simply  an  inhibition  of  secretion,  the 
salty  and  spicy  articles,  even  pepper  and  ginger,  may  be  advised. 

Such  sub-  or  anacidities  are  improved  by  taking  caviar,  sardelles, 
small  pickeled  herrings,  or  anchovies  before  meals,  because  salt  is  an 
approved  stimulant  to  secretion.  In  these  cases  HCl  is  not  only 
supplied  because  of  its  deficiency,  but  also  because  it  is  actually 
curative  in  hastening  the  resumption  of  secretion.  If,  however, 
the  absence  of  HCl  and  ferments  is  due  to  results  of  inflammation 
still  going  on,  all  spices  and  unnecessary  salt  and  foods  containing 
them  must  be  forbidden,  since  they  may  act  as  irritants.  Although 
HCl  is  absent,  it  will  be  found  best  not  to  administer  it  when  it  causes 
symptoms  of  gastric  distress.  In  these  cases,  where  the  mucosa  is 
extremely  sensitive  and  an  atrophic  gastritis  exists,  gastric  diges- 
tion had  best  be  converted  into  an  alkaline  proteolysis  and  amylo- 
lysis.  by  supplying  pancreatin  and  sodium  carbonate.  In  these 
extreme  cases  of  sub-  or  anacidity  it  is  sometimes  found  that 
hydrochloric  acid  gives  pain  and  even  causes  emesis.  Meats  that 
are  given  in  anacidity  must  not  be  too  fresh,  but  properly  seasoned 
and  very  tender  ;  they  must  be  thoroughly  cooked  in  a  steam 
broiler  until  they  almost  fall  apart  into  the  primitive  muscle- 
bundles.  A  practical  way  is  to  rub,  cut,  or  scrape  the  meat  prior  to 
cooking  it.  Finally,  if  in  addition  to  the  anacidity  one  has  reason 
to  believe  that  duodenal  digestion  is  also  disturbed  (from  chronic 
duodenitis,  occlusion  of  the  pancreatic  or  bile  duct,  or  from  carci- 
noma of  the  duodenum,  pancreas,  gall-bladder,  or  liver),  then  the 
administration  of  meat  powders  and  beef  peptones  is  in  order. 
These  substances,  which  are  really  albumoses,  though  capable  of 
satisfying  the  requirements  of  metabolism,  are  not  palatable  and  are 
relatively  expensive.  The  peptones  most  frequently  used  in  Ger- 
many are  those  of  Kemmerich,  Denayer,  and  Maggi.  Ewald  and 
Gumlich  {Berlin,  kliii.  WoclienscJir.,  1890,  No.  44)  have  investigated 
the  qualities  of  a  "  peptone  beer  "  and  found  it  quite  nutritious. 
Boas    speaks    favorably    of    the    American   product    "Mosquera" 


DIETETIC    PREPARATIONS    OF    BEEF. 


191 


Julia  Beef  Meal.  Professor  R.  H.  Chittenden  (in  a  report  to  the 
Philadelphia  County  Medical  Society,  May,  1891)  has  given  the 
results  of  his  analysis  of  American  beef  products,  which  are  found 
in  the  following  table  : 


PERCENTAGE  COMPOSITION  OF  BEEF  PRODUCTS,  ANALYZED  i8qi. 


2 

(Vl    V 

jtn  4) 

m  „ 

U3-C 

'■^  8 

"c  Ji 

c"  .0 

0  0  c 

n-^ 

Constituents. 

c  ■= 

> 

0^ 

l-l 

P 

3 

11 

0 

r^ 

D5 

6  i) 

Water  (at  ilo°C.), 

20.06 

14-03 

60.31 

57.88 

81.09 

83-99 

39-58 

6.80 

6.68 

Solid  matter  (at 

110°  C),  .   .    . 

79-94 

85-97 

39-69 

42.12 

18.91 

16.01 

60.42 

93.20 

93-32 

Soluble  in  water,  . 

50.40 

48.14 

31.26 

Insoluble  in  water, 

0 

0 

0 

0 

0 

0 

10.02 

45.06 

62.06 

Inorganic  constitu- 

ents,       .    .    .    -. 

24.04 

28.29 

11.30 

17-52 

1.02 

0.66 

13-52 

5.08 

4-23 

Phosphoric     acid 

(P2O.O,   .    .         . 

9-13 

7.28 

4.00 

3-94 

0.03 

0.09 

3-91 

1.40 

1. 71 

Fat,    ether   extrac- 

tives,      .         .    . 

0.91 

1.27 

0.78 

0.85 

1.49 

0.27 

1.29 

2-95 

13.60 

Soluble   in   80  per 

cent,  alcohol,     . 

55-72 

67.92 

29-15 

35 -08 

34-10 

Total  nitrogen,  .    . 

9-52 

8.80 

2.68 

3-25 

2.43 

2.29 

7-38 

4.42 

12.36 

Nitrogen  of  insol- 

uble matter,    .    . 

1.46 

3-25 

7-65 

Insoluble     proteid 

matter,    ... 

9.12 

20.30 

47-81 

Soluble  albumin 

coagulable  by 

heat,    .        .    . 

0.06 

0.68 

0-55 

0.47 

13.98 

14.29 

0 

0 

0 

Soluble  albumoses, 

0 

0 

0 

0 

0 

0 

0 

5-44 

11.09 

Peptone,     .... 

0 

0 

0 

0 

0 

0 

0 

1.87 

18.34 

Total  proteid  mat- 

ter  available   as 

nutriment,      .    . 

0.06 

0.68 

0-55 

0.47 

13.98 

14.29 

9.12 

27.61 

77.24 

Nutritive  value   as 

compared     with 

fresh    lean    beef 

(lean  beef  =100), 

0.30 

3-50 

2.80 

2.40 

72.40 

74.00 

47.20 

143-0 

400.00 

It  should  be  stated  in  justice  to  other  manufactured  products 
which  Prof  R.  H,  Chittenden  has  included  in  his  list  for  com- 
parison, that  extract  of  beef  is,  by  a  number  of  firms,  offered  not 
as  a  nutritive  or  food  for  the  sick,  but  as  a  culinary  article,  the 
same  manufacturers  making  also  other  highly  nutritious  foods. 

Armour  &  Company,  of  Chicago,  manufacture  a  valuable  product 
which  is  called  "  Vigoral,"  containing  68  per  cent,  albuminoids.  It 
is  a  saturated  solution,  or  rather  suspension,  of  pure  powdered  beef 


192  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

in  beef  extract.  This  is  not  a  patented  or  proprietary  article,  and 
can  be  conscientiously  recommended.  So  the  table  of  Chittenden's 
comparisons  is  valuable  only  to  show  the  superiority  of  foods  con- 
taining the  beef  in  powder  or  insoluble  form,  to  the  extracts,  which 
represent  only  the  soluble  salts  of  the  beef  and  very  little  of  the 
nitrogenous  constituents — rarely  more  than  eight  per  cent. 

The  Mosquera  beef  meal  is  a  product  that  undoubtedly  has  an 
exceptionally  high  nutritive  value,  the  total  proteid  matter  available 
as  nutriment  being  77.24  per  cent.  It  also  contains  13.60  per  cent, 
fat,  1 1.09  per  cent,  soluble  albumoses,  and  18.34  per  cent,  of  peptone. 
With  Chittenden's  authority  for  this  analysis,  and  our  own  experi- 
ence as  to  its  easy  digestibility  and  perfect  absorption,  this  product 
commands  an  important  place  in  our  dietary  for  sub-  or  anacidity 
and  gastric  atrophy,  particularly  when  associated  with  intestinal 
disease.  The  juice  of  the  pineapple  contains  a  proteolytic  ferment, 
thus  adapting  this  fruit  for  the  treatment  of  cases  where  no  gastric 
juice  is  secreted.  For  its  digestive  effect  the  juice  of  the  fresh 
fruit  only  should  be  swallowed  and  the  fiber  removed  from  the 
mouth.  By  boiling  the  pineapple  the  proteolytic  ferment  is  destroyed. 

When  atony  or  pronounced  dilatation  accompany  any  gastric 
disease,  particularly  those  already  referred  to,  the  dietetic  manage- 
ment is  most  important.  Weakening  and  loss  of  motility  are 
among  the  most  serious  affections  of  the  organ  and  in  the  gravity 
of  their  consequences  outweigh  any  disturbance  of  secretion.  Motor 
insufficiency  may  supervene  upon  any  gastric  disease.  As  a  rule,  the 
chronic  affections  rarely  become  manifest  until  the  motility  is  dis- 
turbed ;  that  is,  until  the  muscular  tonus  relaxes.  Many  times  a 
co-existing  secretory  or  organic  disease  is  the  cause  of  the  dilata- 
tion ;  for  instance,  it  is  generally  admitted  that  hyperacidity  can 
produce  spasm  of  the  pyloric  sphincter  which  the  gastric  peristalsis 
will  be  unable  to  overcome. 

The  section  on  motor  insufficiency  in  the  second  part  of  this 
work  will  consider  fully  the  etiology  of  this  affection.  When  in- 
gesta  remain  in  the  stomach  longer  than  normally,  fermentation, 
gas  formation,  and  distention  eventually  supervene,  causing  stasis 
in  the  muscular  layer  and  dilatation  (Naunyn,  Dcntscli.  Arcli.f.  klin. 
Med.,  1882,  Bd.  xxxi).  In  dilatation  proper — the  deciding  sign  of 
which  is  presence  of  ingesta  in  the  stomach  in  the  morning  after  a 
test-meal  taken  twelve  hours  previously — we  must,  from  a  dietetic 
as  well  as  from  a  therapeutic  standpoint,  distinguish  between  the 


DIETETICS    OF    ATONY    AND    DILATATION.  I93 

myasthenic,  atonic  form  due  to  simple  relaxation  of  the  muscularis, 
and  the  obstructive  form  due  to  pyloric  or  duodenal  stenosis. 

In  the  first  variety  dietetic  and  other  treatment  may  effect  a  cure. 
In  the  stenotic  types  little  beyond  transient  improvement  must 
be  expected,  except  when  the  obstacle  (cicatrix,  carcinoma,  hyper- 
trophied  pylorus,  gall-stones,  peritoneal  adhesions,  etc.)  can  be 
removed  permanently  or  temporarily,  or  where  a  new  route  can  be 
devised  for  the  passage  of  the  chyme.  Here  abdominal  surgery 
asserts  itself,  and  gastro-enterostomy  has  thus  far  produced  the  best 
results.  (See  chapter  on  "  Operative  Treatment  of  Gastric  Diseases.") 

The  dietetic  management  of  dilatation  will  have  regard  not  only 
to  the  injured  muscular  tonus,  but  also  to  the  secretory  or  organic 
disease  with  which  it  may  be  associated.  For  example,  if  it  is 
associated  with  chronic  gastritis,  the  diet  must  be  that  for  this  dis- 
ease and  dilatation  ;  and  if  it  is  combined  with  hyperacidity,  the  diet 
is  the  one  devised  for  this  trouble  and  dilatation.  As  the  funda- 
mental thing  in  dilatation  is  to  prevent  burdening  of  the  muscula- 
ris, the  diet  must  be  as  light  in  weight  as  possible,  and  especially, 
as  far  as  practicable,  exclude  liquids,  for  these  are  not  only  all  heavy, 
but  are,  according  to  von  Mehring,  not  at  all  absorbed  from  the 
stomach  (excepting  alcohol).  The  requisite  amount  of  water  is  best 
given  by  high  sigmoid  enemata :  j/  liter,  slightly  warmed,  two  or 
three  times  a  day.  In  this  manner  a  water  impoverishment  can 
be  prevented  (see  Wegele,  "  Die  atonische  Magenerweiterung  u. 
ihre  Behandlung  ").  An  absolutely  dry  diet  was  suggested  by 
van  Swieten,  Chomel  ("  Des  Dyspesies,"  Paris,  1857),  and  Fossa- 
grives,  but  its  strict  execution,  as  was  developed  by  Schroth,  is 
impracticable,  since  fully  developed  dilatations  require  months,  even 
years,  of  strict  dieting,  which,  if  followed  out  on  these  lines,  would 
inevitably  produce  dangerous  drying  out  of  the  organs  (Kussmaul, 
"  Z.  Behandl.  d.  Magenerweit.,"  Daitsch.  Arch.f.  klin.Med.,  Bd.  vi). 

Although  it  is  not  strictly  a  dietetic  therapy,  yet  lavage  must  be 
mentioned  here.  If  large  masses  of  decomposed  food  are  vomited 
the  stomach-tube  is  indispensable.  Milk  diet,  used  exclusively, 
aggravates  the  symptoms  without  exception.  Should  the  vomit 
or  test-meals  reveal  that  carbohydrates  habitually  disagree  and 
ferment,  an  exclusive  beef  or  meat  diet  for  a  icw  weeks  is  rational, 
and  is  followed  by  less  distention  (Minkowski). 

In  very  severe  and  extreme  cases  of  dilatation  one  may  be  com- 
pelled to  feed  exclusively  by  rectal  enemata,  for  the  preparation  of 


194  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

which  we  refer  to  the  paragraph  on  that  subject.  Soups  and  drinks 
during  meals  must  be  avoided.  Great  thirst  can  be  quenched  by 
taking  small  pieces  of  ice  into  the  mouth.  Patients  that  are  being 
treated  with  lavage  may  be  permitted  to  quench  their  thirst  before 
the  evacuation.  Moritz  has  shown  that  solid  food  is  retained  longer 
than  semi-solid  ;  the  latter  form  is  therefore  preferable.  Meats  are 
given  best  in  scraped  or  finely  chopped  state,  and  must  be  of  the  red 
varieties  and  free  from  fat.  Meat  dumplings  or  balls,  hash  of  fresh 
beef  or  lamb,  Mosquera,  Valentine's,  Wyeth's,  or  Wiel's  beef  jelly, 
are  adapted  to  dilatations  in  which  secretion  is  preserved.  When 
gastric  digestion  is  much  lowered  the  cereal  and  leguminous  pro- 
ducts are  useful.  We  recommend  gruels  made  from  arrowroot, 
tapioca,  rice,  sago,  cerealin,  strained  oatmeal,  to  which  we  are 
accustomed  to  add  some  form  of  diastase,  either  the  taka  diastase 
or  malt  extract.  Aleuronat  flour,  containing  much  digestible 
albumin  (prepared  by  Dr.  Hundhausen,  Hamm,  Westphalia,  Ger- 
many), and  the  soup  meals  of  C.  H.  Knorr  (Heilbronn,  Germany) 
are  of  use  when  prepared  according  to  our  dietetic  directions.  To 
be  digestible,  even  for  healthy  stomachs,  all  leguminous  foods 
must  be  cooked  a  long  time.  For  gastric  sufferers  they  must  be 
used  only  in  a  condition  of  very  fine  subdivision,  and  partial 
de.xtrinization  of  their  starch,  rendering  it  more  soluble.  Besides 
the  products  of  this  character  just  mentioned,  we  have  the  Liebig 
malto-leguminose  (prepared  by  William  Roth,  Jr.,  in  Stuttgart), 
and  the  biscuit-leguminose  (Theodor  Fimpe,  in  Magdeburg).  The 
firm  of  Hartenstein  &  Company,  Chemnitz,  Germany,  prepare 
several  good  leguminous  flours.  (Further  reference  in  Penzoldt 
and  Stintzing's  "  Handbuch  d.  Therapie,"  vol.  iv,  pp.  256-258.) 

The  collection  of  dietaries  will  contain  menus  for  gastric  atony 
and  dilatation  (i)  with  loss  of  secretions  or  anacidity,  (2)  with 
normal  or  augmented  secretions,  (3)  with  serious  stenotic  symptoms. 
In  severe  cases  of  the  latter  type  even  the  most  sparing  diet  by  the 
mouth  will  be  impossible,  and  as  a  last  resource  we  must  fall  back 
on  rectal  enemata.  Sometimes  after  a  week  to  ten  days  of  rectal 
alimentation  the  diseased  condition,  if  it  be  within  the  stomach, — as, 
for  instance,  an  ulcer  or  carcinoma  at  the  pylorus, — becomes  so 
improved  that  partial  mouth-feeding  may  be  resumed. 

The  diet  in  the  various  types  of  carcinoma  coincides  with  that 
of  motor  insufficiency  and  dilatation  whenever  the  neoplasm  is 
causing  the  stenosis.     In  carcinoma  of  those  portions  which  do 


DIET    IN    CARCINOMA.  I95 

not  form  an  obstacle  to  the  exit  of  the  chyme,  and  where  the 
motility  is  good,  the  patient's  appetite  must  be  stimulated  as 
much  as  possible  by  strychnin,  HCl,  bitter  tonics,  condurango, 
etc.,  and  nothing  forbidden,  as  the  physician  must  be  satisfied  if 
the  patients  eat  anything.  As  chronic  gastritis  is  always  present 
even  in  these  cases,  the  diet  list  as  given  for  this  disease  is  ad- 
visable. 

In  cancer  arising  on  the  basis  of  old  gastric  ulcers,  the  ulcus 
carciiiomatosum,  there  is  often  a  pronounced  hyperacidity  which 
naturally  is  best  met  by  the  diet  recommended  for  augmented 
gastric  secretion,  provided  the  stenosis  permits  it. 

Where  the  stenosis  is  at  the  cardia  the  matter  of  proper  alimen- 
tation becomes  difficult. 

As  long  as  the  stenosis,  no  matter  from  what  cause,  can  be  kept 
open  by  bougies  and  sounds,  a  highly  nourishing  liquid  diet  of 
milk,  eggs,  beef  jelly,  beef  meal,  peptone,  nourishing  soups  con- 
taining somatose,  and  wines  are  indicated.  In  rare  cases  we  have 
seen  life  prolonged  by  allowing  the  esophageal  tube  to  remain  in 
situ  and  feeding  through  it  every  two  to  three  hours.  Leyden 
(Leyden-Renvers,  Deutsche  vied.  Wochenschr.,  1887,  No.  50)  and 
Gersunny  (PVien.  nied.  Wochenschr.,  1887,  No.  43)  have  strongly 
indorsed  this  procedure  for  esophageal  strictures  of  carcinomatous 
origin.  After  the  stenosis  is  no  longer  passable  and  gastrotomy 
has  become  necessary,  nutrition  must  be  carried  on  through  the 
gastric  fistula.  According  to  Julius  Friedenwald's  studies  on 
salivary  digestion  it  would  be  logical  to  advise  these  unfortunates 
to  chew  their  food  first,  and  removing  it  from  the  mouth  insert 
it  through  the  fistula.  But  where  this  is  objected  to,  it  is  expe- 
dient to  add  15  grs.  of  ptyalin  to  the  food,  which  must  always 
be  liquid  or  in  the  form  of  paste,  soup,  or  gruel.  Finally,  when  gas- 
trotomy can  not  be  done,  or  permission  thereto  is  refused,  the  only 
way  to  nourish  the  patient  is  by  rectal  enemata.  So  it  is  evident  that 
the  symptoms  and  dietetic  management  of  carcinoma  vary  greatly 
according  to  its  location.  At  present  we  have  under  observation  a 
patient  who  has  a  gastric  tumor  ;  as  far  as  can  be  palpated  it  is  about 
four  inches  long  and  two  inches  wide.  There  has  been  no  evidence 
of  HCl  secretion  for  over  a  year,  but,  as  the  motility  is  very  good, 
there  is  no  lactic  acid  formation.  The  Oppler-Boas  bacillus  has  been 
repeatedly  found  in  the  gastric  contents.  Still,  this  patient,  with 
an  undoubted  carcinoma,  has  gained  12  pounds  in  six  weeks,  and 


196  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

has  no  subjective  complaints  while  in  our  sanitarium  for  digestive 
diseases. 

With  anacidityand  a  fair  peristalsis  a  carbohydrate  diet  is  applic- 
able to  carcinoma,  but  when  HCl  is  well  tolerated  the  various  meats 
must  not  be  forbidden.  Of  these,  Boas  prefers  the  meat  from 
various  fishes.  Where  HCl  is  not  well  tolerated,  pancreatin  is  in 
place.  Lavage  can  not  be  avoided  when  much  fermentation  and 
signs  of  dilatation  are  marked  ;  in  case  these  signs  are  very  annoy- 
ing, a  few  days  of  exclusive  meat  diet  or  of  rectal  feeding  may  be 
necessary  to  restore  somewhat  of  the  lost  gastric  tonicity.  Before 
pyloric  stenosis  is  complete,  the  case  should  be  transferred  to  the 
surgeon,  as  the  resorption  from  the  stomach  itself,  even  if  it  were 
normal,  is  insufficient  to  maintain  life.  Those  materials  that  are 
readily  absorbed  from  a  healthy  stomach,  such  as  peptone,  glucose, 
alcohol,  etc.,  are  given  in  these  cases.  There  is  little  evidence, 
however,  of  their  being  absorbed.  The  good  effects  of  gastro- 
enterostomy consist  not  only  in  the  entrance  made  for  the  food 
into  the  intestine,  whereby  better  digestion  becomes  possible,  but 
also  in  an  improvement  in  the  inflammatory  process  around  the 
neoplasm,  which  is  no  longer  kept  in  constant  irritation  by  stag- 
nating, fermenting  masses  of  food  in  continual  contact  with  it. 
The  main  reason  why  operations  do  not  bring  as  much  relief  and 
improvement  as  is  e.xpected  is  to  be  sought  in  delay  in  performing 
them. 

The  Dietetics  of  Gastric  Ulcer  and  Erosions. — There  are 
three  types  of  gastric  ulcer  which  demand  a  varying  or  separate 
dietetic  treatment.  These  are  :  1 1)  Light  attacks  with  pain,  hyper- 
acidity, and  pyrosis,  but  no  vomiting  of  blood.  (2)  Serious  cases 
that  have  had  hematemesis,  and  still  have  signs  of  it  at  the  time  of 
presentation.  (3)  Old,  chronic,  frequently  relapsing  gastric  ulcers. 
There  are  forms  that  run  a  latent  course,  void  of  symptoms  until 
a  sudden  severe  hemorrhage  surprises  the  patient  and  ph}-sician, 
and  possibly  terminates  the  case.  Erosions  which  have  no  great 
extension  laterally  nor  toward  the  depth,  and  can  be  recognized 
by  fragments  of  mucosa  found  in  the  washwater,  yield  very 
readily  to  an  exclusive  diet  of  milk  combined  with  rest.  During 
the  gastric  hemorrhage  we  advise  that  nothing  at  all  be  given  by 
the  mouth,  not  even  water  ;  nor  ice  pills, — positively  nothing  ;  but 
absolute  rest,  a  hypodermic  injection  of  ^ow.  of  ergotol,  and,  if 
pain  and  restlessness  are   marked,   }^  of   a  gr.   of    morphin   sul- 


DIET    IN    GASTRIC    ULCER.  1 9/ 

phate  hypodermically,  and  a  small  ice  bag  placed  over  the 
epigastrium.  Wiel  claims  to  have  arrested  gastric  hemorrhage  by 
lavage  with  cold  (io°  C.)  or  hot  (42°  C.)  water.  Such  treatment 
in  profuse  bleeding  impresses  one  as  hazardous.  Our  course  has, 
in  a  very  large  number  of  cases,  been,  as  a  rule,  very  satisfactory. 

If  there  is  much  weakness  we  use  the  Boas  or  Ewald  nutritive 
enemata  on  the  day  of  and  following  the  hematemesis  ;  but  if  the 
pulse  is  good  we  dispense  with  them.  On  the  day  following  the 
hemorrhage,  milk  in  teaspoonful  doses  is  given  every  half  hour  ; 
egg-albumen,  if  it  is  taken  willingly,  is  more  fitting,  as  it  combines 
with  a  larger  amount  of  HCl,  and  when  diluted  it  does  not  stimulate 
secretion  in  small  doses. 

Brandy  and  wine  are  to  some  extent  irritating  to  ulcers  and 
excite  more  secretion ;  they  are  accordingly  not  given  except  there 
be  great  prostration.  On  the  third  day  it  will  be  safe  to  proceed 
to  carrying  out  a  Leube  rest-cure,  with  the  consecutive  order  of 
diet  suggested  by  him  or  the  diet  lists  proposed  by  Penzoldt, 
both  of  which  present  four  different  groups  of  food-materials.  Be- 
ginning with  the  simplest  and  most  digestible,  they  gradually  lead 
up  to  a  more  consistent  ordinary  household  menu. 

Each  of  these  four  diet  orders  must  be  persisted  in  from  one 
week  to  ten  days.  Penzoldt's  and  Leube's  diet  orders,  together  with 
our  explicit  diet  lists  for  various  stages  of  gastric  ulcer,  will  be  ap- 
pended. The  principle  underlying  all  treatment  by  food  in  these 
cases  is  to  secure  the  greatest  amount  of  rest  and  such  substances 
as  will  combine  with  the  largest  amount  of  HCl  and  relieve  the 
hyperacidity.  In  a  number  of  cases  of  ulcer  we  have  found  that 
an  amylaceous  diet  was  retained  better  and  caused  less  pain  than 
scraped  beef  or  soft  eggs.  It  is  advised  on  the  same  principles  as 
stated  on  page  189. 

In  chronic  and  frequently  recurring  cases  of  ulcer,  McCall, 
Anderson  {Bj^it.  Med.  JoiLr.,  May  10,  1890),  and  H.  B.  Donkin  {The 
Lancet,  September  27,  1890),  have  had  excellent  results  from  total 
exclusion  of  the  stomach  from  digestion,  by  feeding  with  rectal  ene- 
mata altogether ;  some  of  their  cases  were  nourished  in  this  way  for 
twenty-three  days.  Riegel  {Zeitschr.  f.  prakt.  Aerzte,  1890,  No.  2) 
speaks  enthusiastically  of  this  treatment  in  stubborn  cases  of 
ulcer,  and  Boas  reports  ten  cases,  all  of  which  but  one  were  cured 
by  this  method,  by  giving  three  to  four  of  his  nutritive  enemata 
daily  for   fourteen   days.    We   have   a  personal  experience   of    14 


I9S  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

persistent  cases  of  ulcer  treated  in  this  manner,  together  with 
nitrate  of  silver,  bismuth  subnitrate  internally,  and  rest-cure,  and 
are  disposed  to  look  upon  tlie  treatment  with  great  favor.  An 
ulcer  must  not  be  considered  cured  until  there  is  no  more  epigas- 
tric pain  on  pressure  and  the  patient  gains  weight  (Gerhardt). 

The  trea':ment  of  the  sensory  gastric  neuroses,  to  be  effective, 
must  combine  a  number  of  remedial  agents  with  diet. 

Hyperesthesia,  gastrodynia  or  gastralgia,  and  neurasthenia  gastrica 
are  morbid  states,  the  treatment  of  which  must  be  largely  directed  to 
the  central  nervous  organs.  The  same  must  be  said  of  the  motor 
neuroses  :  Cardiospasm  and  pylorospasni,  nervoiis  vomiting,  rumina- 
tion, KussmanTs  peristaltic  unrest,  ijicontinence  of  the  cardia  and  of 
the  pylorus.  These  diseases  demand  electric,  hydropathic,  climatic, 
and  medicinal  measures,  and  massage. 

Avery  careful  investigation  into  possible  causative  constitutional 
morbid  states  (anemia,  gout,  rheumatism,  tuberculosis,  chlorosis, 
uric  acid  diathesis)  will  often  reveal  a  removable  underlying  etio- 
logical foundation.  Fliess  has  reported  cases  of  gastralgia  and 
vomiting,  emanating  reflexly  from  the  nasal  mucosa,  and  has  cured 
them  by  local  treatment  ("  Neue  Beitr.  z.  Klinik  u.  Therapie  d.  Nasal- 
Reflexneurose").  In  a  similar  way  attention  to  gynecological  dis- 
orders in  the  female  and  genito- urinary  diseases  in  the  male  have 
led  to  the  cure  of  distressing  nervous  dyspepsias.  In  the  gastric 
neuroses  of  motor  or  sensory  type  the  diet  must  be  based,  as  in  all 
previous  diseases,  as  far  as  is  expedient,  upon  the  state  of  the  secre- 
tion and  motility.  When  the  general  nutrition  is  disturbed,  the 
plan  of  treatment  most  generally  adopted  is  a  fattening  rest-cure 
according  to  the  principles  laid  down  by  Weir  Mitchell  and  Play- 
fair.  This  treatment,  though  not  universally  applicable,  is  the  one 
most  to  be  employed  in  nervous  vomiting  of  hysterical,  ane- 
mic, and  chlorotic  origin,  and  in  stubborn  cases  of  anorexia  and 
gastralgia.  It  is  somatic  and  psychical  at  the  same  time.  We  have 
had  ample  opportunity  to  test  the  dietetic  part  of  this  treatment  as 
it  has  been  developed  by  Burkart  in  Germany  ( K?//t'Wrt;/«'.y  klin. 
Vorii'age,  No.  245).  And  cases  of  the  types  described  have,  in  our 
local  sanitarium  and  in  the  Maryland  General  Hospital,  been  com- 
pletely cured.  Of  course,  organic  and  structural  changes  in  the 
digestive  organs  render  the  proper  nutrition  impossible. 

Contra- indications  to  fattening  cures  are  :  Cerebral  excitation  or 
depression  ;  hysteria,  with   uncontrollable   vomiting  ;   and  visceral 


DIET  IN  SENSORY  NEUROSES.  1 99 

neuralgias,  which  are  expressions  of  sympathetic  nerve  dis- 
eases. 

The  best  results  with  Weir  Mitchell's  rest  and  fattening  cures  are 
obtained  in  neurasthenic  or  hysterical  anorexia  with  much  emaci- 
ation but  where  there  is  no  digestive  disease.  Wherever  the 
nervous  dyspepsia  is  accompanied  by  gastritis,  atony,  or  dilatation, 
fattening  cures  may  easily  cause  pain,  pressure,  vomiting,  and 
diarrhea  ;  so  that  if  such  cures  are  attempted  because  everything 
else  has  been  tried,  one  must  be  cautious  not  to  persist  in  system- 
atic introduction  of  large  amounts  of  food,  even  in  divided  portions, 
as  the  frequently  repeated  small  portions  may  accumulate  in 
atony,  etc.,  and  aggravate  the  symptoms. 

Burkart  begins  with  lOO  gm.  of  milk  with  Zwieback  every  two 
hours,  and  increases  it  so  that  two  to  three  liters  of  milk  per  day 
are  taken  after  fourteen  days  of  treatment.  The  milk  may  be 
flavored  with  sugar,  cocoa,  tea,  lime-water,  or  salt,  according  to 
taste ;  and  after  a  few  days  other  articles  of  diet  are  cautiously 
sandwiched  in.  We  give  Burkart's  complete  menu  among  our 
diet  tables. 

Neurasthenia  gastrica  (Ewald),  or  the  nervous  dyspepsia  of 
Leube,  when  it  occurs  in  males,  is,  in  our  experience,  not  benefited 
by  the  methods  of  Weir  Mitchell  or  Burkart.  Here  more  than 
ever  the  physician  must  endeavor  to  remove  the  cause  if  possible 
(excess  in  tobacco,  overwork,  uric  acid  diathesis,  sexual  over- 
indulgence). A  definite  diet  can  not  be  given  because  there  are 
rarely  two  cases  alike;  the  dietetic  treatment  of  nervous  dyspepsia 
is  difficult,  the  strictest  individualization  is  requisite. 

The  prognosis  as  regards  perfect  recovery  is  doubtful.  An 
attempt  with  the  Leube  or  Penzoldt  order  of  dieting  is  not  only 
rational  but  sometimes  productive  of  lasting  improvement. 

The  Indications  for  Predigested  Foods  :  Peptones,  Albu- 
moses,  Dextrose,  etc. — The  idea  of  suppl}-ing  foods  that  would 
replace  the  lost  digestive  function  of  the  stomach  or  by  presenting 
them  in  an  absorbable  form  that  would  spare  the  work  which  it  had 
become  incapable  of  performing,  was  suggested  by  the  recogni- 
tion of  diseases  that  tended  to  destroy  the  glandular  apparatus,  or 
caused  emesis  of  the  ingested  food. 

In  such  instances  in  which  the  amount  of  albuminous  foods 
that  can  be  taken  is  very  small,  the  question  has  been  raised 
whether  peptones  are  able  to  equalize   the  deficit  of  albumin  re- 


200  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

quirement.  As  a  certain  amount  of  albuminous  food  is  indispensa- 
ble to  life,  whenever  the  quantity  ingested  sinks  below  the  so-called 
threshold  value  of  albumin  ("  Schwellenwerth "),  health  begins 
rapidly  to  decline.  Deiters  has  shown  (von  Noorden,  "  Beitr.  z. 
Lehre  V.  Stoffverlust  d.  gesund.  u.  krank.  Menschen,"  Heft  i,  1892) 
that  even  when  the  amount  of  albumin  ingested  sinks  below  the 
threshold  value,  peptones  and  albumoses  (Denayer's  mixture)  are 
capable  of  maintaining  the  body  in  nitrogenous  equilibrium.  Kuhn 
confirmed  this  observation  in  Riegel's  laboratory  with  regard  to  an 
albumose  mixture  selling  under  the  name  of  somatose ;  so  that 
we  may  conclude  that  these  products  can  replace  food-albumin 
for  a  time  at  least;  still,  we  doubt  very  much  whether  it  is 
expedient  or  necessary  to  give  peptones  and  albumoses  in  larger 
quantities.  Their  expensiveness  would  be  no  serious  objection  if 
the  advantages  of  their  use  were  very  obvious. 

In  secretory  insufficiency  of  the  stomach  it  is  well  known  that 
the  proteolytic  power  of  the  intestine  will  utilize  most  of  the  unal- 
tered proteid. 

Even  where  the  stomach  is  excluded  from  digestion  entirely, 
albumin  is  used  up  to  a  sufficient  degree  (Ogata,  ArcJi.  f.  Anat.  n. 
Physiol.,  1883,  S.  89).  Loss  of  peptic  function,  therefore,  does  not 
prevent  sufficient  utilization  of  albumin.  There  is  an  apparent 
advantage  in  the  bland  and  unirritating  quality  of  peptones,  but 
certainly  this  is  possessed  also  by  certain  undigested  foods  (milk, 
egg-white).  Peptones  and  albumoses  are  not  absorbed  more 
readily  when  ingested  ready-formed,  than  when  they  are  first  devel- 
oped from  albumin  in  the  stomach  (Cahn,  "  Die  Verwendung  d. 
Pepton  als  Nahrungsmittel,"  Berlin,  klin.  Wocliensclir.,  1893,  No.  24). 

They  are  said  to  produce  diarrhea  ;  but  to  establish  this  fact  the 
quantity  of  artificial  peptone  and  the  amount  of  nitrogen  in  the 
remaining  ingesta  must  be  considered  together. 

As  an  indication  for  the  use  of  the  predigested  foods,  we  may 
state  the  conditions  where  the  albumin-dissolving  power  of  the 
stomach  is  permanently  reduced  or  lost,  where  the  amount  of  meat- 
and  egg-ingestion  becomes  insufficient  because  of  efforts  necessary 
to  avoid  mechanical  irritation  ;  if  duodenal  digestion  is  also  de- 
ranged, the  indication  becomes  more  urgent.  When  the  secretory 
function  is  lost  but  the  motility  preserved,  the  vicarious  intestinal 
proteolysis  will  digest  sufficient  proteid.  When  peristalsis  is,  how- 
ever, also  lost,  then  the  administration  of  peptones  is  of  no  benefit, 


RECTAL    ALIMEXTATION.  201 

for  we  agree  with  Cahn  {loc.  cit)  that  in  gastrectasia  dependent 
upon  pyloric  stenosis,  peptones  are  not  absorbed,  but  remain  in  the 
stomach  just  as  water  does.  Riegel  (Joe.  cit.,  p.  241),  considers  this 
deduction  of  Cahn's  as  erroneous,  because  von  Mering  has  shown 
that  the  stomach  never  absorbs  water,  but  does  absorb  peptone. 
To  this  we  would  reply,  that  von  Mering  did  not  experiment  upon 
dilatations  dependent  upon  stenosis,  but  upon  normal  stomachs. 

In  his  experiments,  Cahn  found  that  peptone  causes  an  increased 
flow  of  the  gastric  juice,  and  it  was  suggested  that  therefore  it 
should  not  be  given  in  hyperacidity  and  hypersecretion,  in  which 
evidently  it  is  quite  unnecessar\',  as  in  these  secretory  abnormalities 
meat  and  e.gg  are  digested  excellently.  In  ulcer,  peptones  may  find 
temporary  usefulness  because  of  their  unirritating  qualities,  which, 
of  course,  would  be  counterbalanced  b\'  their  effect  in  increasing 
the  HCl,  should  this  be  confirmed. 

In  conclusion  we  may  state  our  personal  custom  in  the  use  of 
these  substances.  \Vhene\er  the  ingestion  of  albumin  in  the  food 
becomes  insufficient,  or  even  where  it  is  ingested  in  sufficient 
amounts  for  a  healthy  individual,  but  owing  to  some  consuming 
disease,  such  as  carcinoma  (not  hindering  peristalsis),  tuberculosis, 
etc.,  it  can  not  cover  the  nitrogen  equilibrium,  in  the  amounts 
possible  to  eat  in  ordinary  diet,  there  we  employ  peptones  and 
albumoses  liberally,  and  generally  so  mixed  with  the  food  (soups, 
scraped  broiled  meats,  in  puree)  that  the  patient  can  not  detect 
them  ;  for  this  purpose  the  taste-  and  odorless  products, — somatose, 
Mosquera  beef  meal,  etc., — are  preferable. 

Rectal  Alimentation. — In  diseases  in  which  the  approach  to 
the  stomach  is  stenosed  (carcinoma,  or  stenosis  of  the  esophagus 
or  cardia),  or  in  which  the  organ  requires  a  temporary  but  absolute 
exemption  from  work  (ulcer  and  some  forms  of  gastritis),  or  in 
cases  in  which  the  mildest  and  most  digestible  diet  is  not  tolerated, 
it  becomes  necessary  to  support  the  strength  b\-  nutriti\-e  rectal 
enemata. 

The  history  of  the  evolution  of  the  nutritive  enema  is,  from  a 
physiological  standpoint,  very  interesting;  and  as  we  have  at 
various  times  done  considerable  experimental  work  in  this  line, 
a  brief  review  of  the  same  is  believed  essential  to  a  proper  under- 
standing of  the  subject. 

The  first  to  disco\'er  that  the  human  colon  and  rectum  absorbed 
an  emulsion  of  eggs  and  water  only  when  sodium  chlorid  was 
14 


202  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

added,  were  Voit  and  Bauer  {Zeitsclir.f.  Biol.,  1869,  Bd.  v).  They 
found  that  these  foods  were  not  absorbed  in  the  absence  of  salt, 
and  in  1871  Eichhorst  {^Pldugers  ArcJiiv,  Jalirgang  iv,  71)  con- 
firmed their  results.  Injections  of  bouillon,  milk,  and  eggs  had 
been  used  long  before  this  time,  but  no  one  ever  attempted  to 
ascertain  to  what  degree  the  mucosa  of  the  large  intestine  would 
absorb  it.  In  1872  Leube  proposed  a  meat-pancreas  injection 
[Deidsch.  Aj'chiv  f.  klin.  Med.,  Bd.  x,  Reihe  iii),  the  plan  emanating 
from  the  idea  to  transpose  something  of  the  character  of  pancreatic 
digestion  into  the  large  intestine.  The  preparation  of  this  useful 
enema  is  as  follows  :  Take  150  to  300  gm.  of  very  finely  scraped 
beef  and  50  to  100  gm.  of  finely  chopped  pancreas  of  the  calf  or 
pig,  and  mix  with  the  addition  of  150  c.c.  luke-warm  water  in  a 
bowl ;  if  desired,  25  to  50  gm.  of  fat  may  be  added  in  the  form  of 
oil  or  butter;  the  injection  must  be  made  at  the  body  temperature. 

We  have  convinced  ourselves  that  this  mixture  digests 
thoroughly  in  the  large  intestine ;  its  preparation  is  complicated, 
however,  requiring  very  intimate  mixing.  Leube  reported  a  case 
which  he  kept  alive  six  months  by  this  enema  exclusively,  and  in 
a  similar  way  Riegel  nourished  a  case  of  esophageal  stricture  for 
ten  months.  Ewald  demonstrated  that  &g%  emulsion  is  absorbed 
without  being  peptonized  or  salted  {ZeitscJir.  f.  klin.  Med.,  Bd.  11), 
and  Huber,  while  confirming  Ewald's  observation,  added  that  the 
addition  of  salt,  or  previous  peptonizing,  really  doubled  the  amount 
of  emulsified  eggs  that  was  absorbed  in  the  colon.  Eggs,  it  must 
not  be  overlooked,  contain  a  considerable  amount  of  normal  salt, 
and  this  may  explain  Ruber's  Y^suXts  {Zeitschr.  f.  kli)i.  Med.,  Bd. 
XLVii)  as  to  their  absorption  in  part,  even  without  the  addition  of 
salt.  But  it  is  an  established  fact  that  the  addition  of  sodium 
chlorid  very  much  increases  the  amount  of  eggs  that  is  absorbed. 

In  a  very  interesting  series  of  experiments  Griitzner  offered  a 
physiological  explanation  of  this  phenomenon  {^Deutsche  vied. 
Wochenschr.,  1894,  No.  48),  having  demonstrated  that  under  cer- 
tain conditions  particles  of  charcoal,  finely  cut  horse-hair,  or  saw- 
dust, impregnated  with  normal  (0.6  per  cent.)  salt  solution  and 
injected  into  the  rectum  of  rabbits,  guinea-pigs,  and  rats,  are  found 
six  hours  later  all  along  the  small  intestine,  even  in  the  stomach, 
while  the  rectum  is  empty.  During  a  period  of  twenty-four 
hours  before  these  injections,  the  animals  were  starved.  When  the 
suspensions  of  these  particles  were  made  in  distilled  water,    HCl 


INTESTINAL    PERISTALSIS    AND    ANTIPERISTALSIS.  2O3 

solution,  or  potassium  chlorid  solution,  instead  of  physiological 
salt  solution,  the  particles  did  not  ascend  in  the  digestive  tract. 
Griitzner  injected  starch-suspensions  in  normal  NaCl  solution  into 
the  rectum  of  human  beings,  and  after  a  number  of  hours  demon- 
strated starch  grains  in  the  gastric  contents,  microscopically. 
Nothnagel  first  showed  that  sodium  chlorid  placed  on  the  serous 
surface  of  the  intestine  is  capable  of  starting  antiperistaltic  move- 
ments ("  Beitrag  z.  Physiol,  u.  Pathol,  d.  Darms,"  1884),  and 
Griitzner  interprets  this  observation  as  an  explanation  of  the 
digestion  of  egg-enemata  containing  salt.  He  assumes  that  the 
injected  mass  "is  moved  upward  through  the  entire  small  intestine, 
and  so  becomes  digested  and  absorbed.  Even  Riegel  {loc.  cit. 
p.  245)  is  satisfied  with  this  interpretation,  and  adds  that  it  ex- 
plains the  negative  results  of  Voit  and  Bauer  without  salt,  and  the 
positive  ones  with  salt,  and  also  those  of  Huber. 

In  our  opinion,  the  evidences  that  food-substances  move  anti- 
peristaltically  upward  in  the  intestine  are  not  satisfactorily  given  in 
Griitzner's  work.  It  is  undeniable  that  minute  particles  of  starch, 
charcoal,  etc.,  are  moved  from  the  rectum  toward  the  stomach  in 
man  ;  and  we  have  been  able  to  confirm  this  part  of  his  results,  as 
well  as  the  fact  that  salt  favors  the  ascent  and  HCl  and  KCl  im- 
pede it.  But  this  antiperistaltic  motion  we  conceive  to  be  only  a 
very  feeble  marginal  ascending  movement,  effected  by  surface  con- 
tact of  the  particles  with  the  epithelium,  which  in  turn  is  moved 
by  the  muscularis  mucosae.  This  very  slight  marginal  antiperis- 
talsis  is  never  visible  to  the  eye,  and  can  only  be  demonstrated  by 
the  progress  of  particles  ;  it  is  not  capable  of  propelling  food  masses  ; 
on  the  contrary,  we  have  proven  that  at  the  same  time  that  the 
marginal  peristalsis  drags  visible  particles  of  charcoal  toward  the 
stomach  with  infinitesimal  slowness,  there  is  an  uninterrupted 
current  of  central  food  masses  toward  the  anus.  The  marginal 
antiperistalsis  may  be  a  physiological  thing,  present  at  all  times, 
and  its  object  may  be  the  raising  or  drawing  up  of  portions  of 
mucosa  from  one  place  to  another  in  order  to  bring  new  surfaces 
in  contact  with  the  ingesta,  or  to  replace  a  portion  of  surface  to  its 
normal  topography  after  it  has  been  dragged  away  from  it  by  the 
downward  current.  The  cohesion  of  these  small  particles  with 
the  mucosa  can  be  seen  when  a  piece  of  fresh  animal  intestine  is 
sprinkled  with  lycopodium  or  finely  cut  horse-hair  particles  and 
held    under   a   gentle   stream   of  water;   the   gut   may   be    moved 


204  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

upward  on  the  surface  of  the  hand  while  the  water  moves  down- 
ward, and  still  many  of  the  particles  will  adhere. 

The  antiperistalsis  that  Nothnagel  produced  by  placing  crystals 
of  salt  upon  the  serosa  is  quite  a  different  thing,  for  it  is  plainly 
visible  to  the  eye,  and  never  occurs  under  physiological  condi- 
tions (Nothnagel,  "  Erkrank.  d.  Darms,"  portion  on  "  Die  Darm- 
bewegung,"  p.  6,  1896).  Among  the  abnormal  conditions  that  may 
cause  this  visible  antiperistalsis,  Nothnagel  states  stronger  solu- 
tions of  sodium  chlorid  and  the  introduction  of  food  at  an  unphysio- 
logical  entry,  as  which  in  man  we  must  consider  the  rectum.  He 
adds  {loc.  cit)  that  from  a  physiological  entry,  i.  e.,  from  the  stomach, 
the  strongest  chemical  irritants  produce  only  peristaltic  movements 
toward  the  anus.  There  are,  then,  two  kinds  of  antiperistaltic  move- 
ments :  (i)  Those  of  Griitzner,  being  marginal,  invisible,  possibly 
physiological,  and  not  capable  of  moving  food  masses ;  (2)  those 
of  Nothnagel,  being  visible,  strong,  and  occurring  only  under 
abnormal  conditions.  Christomanos,  a  pupil  of  Nothnagel,  has 
urged  an  objection  against  Griitzner's  results  that  seems  to  invali- 
date the  conclusions  of  the  latter  ;  namely,  he  found  (Christomanos, 
"  Z.  Frage  d.  Antiperistaltik,"  Wien.  klin.  Rundschau,  1895,  Nos.  12 
and  13)  that  when  his  animals  were  prevented  from  licking  up  the 
expelled  rectal  contents  his  results  as  to  finding  the  particles  in  the 
stomach  were  negative.  Dauber  came  to  the  same  conclusion  as 
Christomanos,  namely,  that  the  occurrence  of  particles  of  rectal 
injections  in  the  stomachs  of  animals  did  not  take  place  when  they 
were  prevented  from  eating  their  excrement.  These  objections  are, 
however,  set  aside  by  Griitzner's  and  our  own  observations  on  the 
human  subject.  The  experiments  of  Swiezynski  {Deutsche  ined. 
Wochenschr.,  1895,  No.  32)  also  confirmed  Griitzner's  statements,  in 
that  lycopodium  injected  into  the  rectum  was  found  in  the  stomach. 

We  must,  however,  again  emphasize  that  this  antiperistalsis  is  not 
capable  of  moving  ingesta,  and  that  it  can  not  logically  be  taken  as 
an  explanation  of  the  digestion  of  enemata. 

If  liquid  enemata  can  be  worked  well  up  into  the  small  intestines, 
why  is  it  that  the  liquid  and  semiliquid  stools  are  not  pushed  up 
into  the  stomach  also  under  normal  conditions?  The  fact  that 
normal  salt  solution  favors  the  invisible  marginal  ascent  of  parti- 
cles, and  that  other  chemicals  impede  it,  is  perfectly  natural.  For  if 
this  antiperistalsis  be  physiological,  and  be  assumed  to  be  going 
on  at  all  times,  normal  salt  solutions  can  not  disturb  it,  for  they  are 


RECTAL    CONTEXTS    AFTER    STERILIZATION.  205 

the  physiological  environment  in  which  all  intestinal  movements 
occur.  But  HCl  and  KCl  are  chemical  irritants,  to  which  the  mus- 
cularis  mucosae  reacts  by  efforts  at  expulsion. 

The  Occurrence  of  Proteolytic  Ferments  in  the  Colon  and 
Rectal  Contents. — The  author's  explanation  of  the  digestion  of 
egg  and  milk  emulsions  in  the  rectum  and  colon  is  quite  different 
from  Griitzner's  and  from  that  accepted  by  Riegel  and  others,  and 
is  based  on  a  very  carefully  conducted  series  of  experiments  on  ani- 
mals and  human  beings.  We  desire  to  speak  only  of  actual  diges- 
tion, for  there  is  good  reason  for  believing  that  albumen,  fats,  etc., 
may  be  absorbed  from  the  rectum  as  such — without  digestion. 

Without  going  into  the  details  and  technic  of  these  experiments 
we  will  briefly  state  the  conclusions.  After  the  rectal  contents  of 
dogs  or  cats  are  sterilized  with  saturated  solutions  of  thymol  (so 
strong  that  the  crystals  float  on  top)  and  passed  through  a  Pasteur 
filter,  control-cultures  are  made  to  ascertain  that  the  watery  extract 
of  the  excrement  is  sterile.  For  this  purpose  the  meat  pepton- 
gelatin  and  agar  plates  recommended  by  Nothnagel  {/oc.  cit.,  p.  22) 
are  most  convenient.  The  reaction  of  human  excrement  is  gener- 
ally weakly  alkaline  or  neutral,  very  rarely  weakly  acid,  under 
normal  conditions.  This  watery  extract  of  normal  rectal  contents 
contains  a  substance  which  in  a  digestorium  (thermostat  at  40°  C), 
and  in  an  alkaline  medium  (equal  to  from  0.8  to  i  per  cent.  NajCOs), 
dissolves  from  ^6. J  to  §0  per  cent,  of  Mercks'  dried  serum- albumin  in 
three  hours.  It  will  also  digest  fibrin,  and  has,  in  addition  a  faint 
amylolytic  power,  converting  from  10  to  14.5  per  cent,  of  starch 
into  maltose  in  an  alkaline  medium  of  0.3  per  cent.  NaoCOs.  We 
have  not  been  able  to  find  any  fat-splitting  effect. 

Now,  as  there  are  many  bacteria  that  produce  peptone  in  the 
breaking  down  of  proteid,  and  others  that  ferment  carbohydrates, 
the  previous  sterilization  is  necessary  in  order  to  exclude  their 
action.  Bacteria  do  not  make  peptone  for  any  philanthropic  pur- 
poses ;  the  peptone  they  give  rise  to  is  an  intermediate  stage  in  a 
long  series  of  decomposition  products.  It  does  not  remain  peptone, 
but  is  rapidly  decomposed  into  amido-acids,  ammonia,  tyrosin,  etc. 
We  state  this  because  even  among  medical  men  the  opinion  has 
been  encountered  that  the  bacterial  peptone  might  be  of  utility  to 
the  organism  in  which  it  is  formed.  The  feces  for  our  purposes 
can  not  be  sterilized  by  heat,  because  that  would  destroy  any 
possible  enzymes  present. 


206  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

It  is  certain,  therefore,  that  rectal  contents  contain  a  proteolytic 
ferment;  also  one  having  a  slight  amylolytic  power,  acting  only  in 
a  faintly  alkaline  medium,  the  action  being  destroyed  in  an  acid 
medium.  Whether  these  two  digestive  actions  are  carried  out 
by  one  and  the  same  ferment  or  by  two  different  ferments  we  are 
unable  to  say.  That  it  can  not  be  pepsin  is  proven  by  the  fact 
that  it  does  not  act  in  an  acid,  but  only  in  an  alkaline,  medium. 

It  would  be  interesting  to  learn  whether  the  walls  of  the  large 
intestine  secrete  any  proteolytic  ferment.  The  colon  of  a  dog  that 
is  kept  clear  of  fecal  masses  by  making  an  abdominal  fistula  and 
sewing  it  to  the  abdominal  wall  at  the  ileocecal  valve,  secretes  an 
alkaline  fluid,  which,  however,  has  no  proteolytic  powers  what- 
ever, but  there  is  an  evident  amylolytic  ferment  contained  in  it. 
The  human  colon  can  be  plugged  up  in  the  transverse  portion  by 
introducing  a  balloon  and  blowing  it  up;  thereafter  the  part  be- 
tween the  rubber  balloon  and  the  anus  is  washed  out  with  sterile 
normal  salt  solution.  A  secretion  is  formed  in  two  to  three  hours 
and  can  be  collected  on  absorbent  cotton,  placed  in  the  rectum, 
and  later  squeezed  out  into  a  small  beaker.  The  secretion  is  alka- 
line, but  has,  after  filtration  through  a  Pasteur  filter,  no  proteolytic 
power.  Therefore,  it  is  reasonable  to  assume  that  the  ferment  we 
have  demonstrated  is  derived  from  the  pancreas.  In  two  patients 
with  total  atrophy  of  the  gastric  mucosa  (atrophic  gastritis),  as 
evidenced  by  fragments  of  the  mucosa  found  in  the  washwater,  the 
same  proteolytic  ferment  was  demonstrable  in  the  colon  contents. 
It  was  hitherto  assumed  that  the  ferments  of  the  pancreas  were 
destroyed  in  the  intestine  (see  Rosenheim,  "  Die  Erkrank.  d. 
Darms,"  p.  46).  A  large  number  of  similar  experiments  as  above 
described  justifies  the  belief,  however,  that  trypsin  and  perhaps 
amylopsin  may  survive  the  passage  through  the  bowel.  Busch 
has  shown  that  digestion  may  go  on  in  the  human  intestine 
without  gastric  or  pancreatic  juice,  without  bile  and  secretion 
of  Brunner's  glands  (Briicke's  "  Vorlesungen  iiber  Physiologic," 
Wien,  1885,  p.  352).  The  patient  on  whom  Busch  experimented 
had  received  an  abdominal  injury  by  an  accident  in  such  a  manner 
that  the  gastric  juice,  together  with  the  chyme,  pancreatic  juice, 
duodenal  secretions,  and  bile,  ran  outward  through  a  fistula. 
Thereafter,  Busch  fed  him  through  the  fistulous  opening  com- 
municating with  the  lower  bowel,  and  succeeded  in  maintaining 
the    nitrogenous    equilibrium.     He    lowered    coagulated    albumin 


PREPARATION  OF  RECTAL  EXEMATA.  20/ 

inclosed  in  small  cotton  bags  into  the  bowel,  and  drew  them  out 
by  a  string  five  hours  later,  finding  that  from  five  to  35  per  cent. 
of  the  albumin  was  dissolved.  In  Busch's  experiments  the  action 
of  the  bacteria  can  not  be  excluded ;  the  action  of  the  succus 
entericus  may  explain  the  carbohydrate  digestion,  but  as  no 
proteolytic  ferment  could  enter  the  small  intestine,  the  digestion 
of  albumin  was  probably  due  to  bacteria. 

In  conclusion  we  may  say  that  rectal  enemata  are  digested 
probably  by  pancreatic  ferments  passing  through  the  bowel,  by 
bacteria,  and  by  the  succus  entericus,  which,  even  in  the  colon,  has 
an  amylolytic  action  ;  that  certain  foods — egg-albumen,  fats,  milk — 
can  be  absorbed  as  such  without  being  digested.  Griitzner's 
marginal  ascending  motion  of  particles  can  not  move  ingesta 
upward.  F.  Mall  ("  Johns  Hopkins  Hospital  Reports,"  vol.  i, 
p.  70)  holds  that  the  propelling  force  of  the  intestines  normally 
acts  in  one  direction  only;  the  antiperistalsis  is  only  found  as  a 
pathological  phenomenon,  and  all  of  his  efforts  to  force  the  intestine 
to  work  in  the  wrong  direction  by  reversal  Hoc.  cit.,  p.  93)  were 
negative.  Under  conditions  of  great  irritation  rectal  contents  may 
be  vomited. 

Preparation  of  Rectal  Enemata: 

Indications  and  Methods  of  Administration. — The  preparation  of 
Ewald's,  Leube's,  and  Boas'  nutritive  enemata  is  given  under  the 
dietetic  tables.  Jaccoud  recommends  250  gm.  of  bouillon,  120  gm. 
of  wine,  yolks  of  two  eggs,  5  to  20  gm.  of  peptone.  Rosenheim  uses 
peptone  (one  to  two  dramsj,two  eggs,  15  gm.  of  glucose,  and  some- 
times, if  desired,  emulsions  of  cod-liver  oil.  Singer's  &nem3.[Central- 
blatt  d.  ges.  Therap.,  Marz,  1895)  is  very  much  like  that  of  Boas, 
with  the  addition  of  peptone.  These  examples  will  amply  suffice 
for  all  purposes. 

Method : 

(i)  Every  nutritive  injection  must  be  preceded  by  a  cleansing  in- 
jection one  hour  previously. 

(2)  The  amount  of  injected  nutriment  must  not  exceed  ]l  of  a 
liter  (oviij)  at  a  time. 

(3)  After  the  injection  the  patient  must  remain  in  the  recumbent 
position  for  one  hour,  and  a  hot  towel  should  be  held  firmly 
against  the  anus  for  fifteen  or  twenty  minutes. 

(4)  The  patient  should  lie  on  his  left  side  with  his  hips  raised 
upon  a  pillow,  and  the  injection  must  be  given  very  gradually. 


208  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

(5)  If  the  rectum  is  very  irritable,  Riegel  recommends  the 
addition  of  a  few  drops  (10  to  20)  of  tr.  opii. 

(6)  The  injection  should  be  made  with  a  funnel  or  an  irrigating 
bottle,  never  with  a  syringe.  The  best  tube  to  use  is  that  named 
after  Langdon,  as  it  is  sufficiently  soft  and  flexible  and  can  not 
kink  upon  itself 

(7)  The  tube  should,  in  adults,  be  passed  high  up  into  the  colon  ; 
if  possible  14  to  18  inches  should  be  introduced,  but  12  inches  will, 
as  a  rule,  suffice.  The  higher  up  the  enema  is  placed  the  less  will 
be  the  liability  of  its  rejection.  An  anatomical  and  physiological 
reason  for  placing  injections  high  is  found  in  the  nature  of  the 
anastomoses  of  the  vascular  supply  of  the  rectum,  sigmoid,  and 
colon.  The  superior  rectal  and  sigmoid  veins  communicate  with 
the  inferior  mesenteric  vein,  therefore  these  veins  conduct  whatever 
they  have  absorbed  directly  to  the  liver  through  branches  of  the 
vena  porta.  In  the  liver  the  very  important  secondary  digestion 
takes  place.  The  veins  from  the  lower  third  of  the  rectum  com- 
municate with  the  inferior  vena  cava,  and  their  contents  are  not 
conducted  to  the  liver. 

(8)  The  temperature  of  the  injection  should  be  that  of  the  body 
—98.6°  F. 

Indications  Necessitating  Rectal  Feeding. — There  are  two 
classes  of  conditions  in  which  nutritive  enemata  are  indicated. 

I.  The  first  class  comprises  patients  that  are  still  able  to  swallow 
food  and  willing  to  do  so,  but  on  account  of  the  existence  of  some 
gastric,  esophageal,  or  duodenal  disease  it  is  expedient  to  rest  the 
stomach  and  exempt  it  from  work.     These  are : 

(i)  Gastric  Ulcer. — For  the  purpose  of  keeping  the  ulcer  free 
from  irritation  and  permitting  it  to  heal  or  to  prevent  the  starting 
up  of  hematemesis. 

(2)  Dilatations. — Either  in  the  atonic  or  benign  forms  to  attempt  a 
cure  by  relieving  the  stomach  of  the  weight  of  ingesta  and  the  con- 
stant fermentation  ;  or  in  the  malignant,  pyloric,  and  stenotic  forms, 
because  food  positively  can  not  pass  the  pylorus  and  gastro-enter- 
ostomy  is  refused  or  impossible. 

(3)  Severe  gastric  irritations,  as  in  toxic  gastritis. 

(4)  Exhausting  diseases,  especially  the  infectious  types,  where 
secretion  and  absorption  are  inhibited  and  food  not  retained, 
though  swallowed. 

(5)  Ulcer  of  the   esophagus  or  duodenum,  stricture,  ileus,  invag- 


INTRAVASCULAR    AND    HYPODERMIC    FEEDING.  2O9 

ination,  volvulus,  stenosis  of  any  part  of  the  alimentary  tract  be- 
tween stomach  and  rectum. 

II.  The  conditions  in  wliich  the  patients  are  unable  to  swallow 
food  are  : 

(i)  Temporary  obstruction  to  the  entrance  of  food  into  the  ali- 
mentary canal;  presence  of  new  growths;  foreign  bodies;  acute  in- 
flammations about  mouth,  pharynx,  esophagus. 

(2)  Extreme  sensitiveness  of  the  mouth  and  esophagus  excited 
by  corrosive  poisons. 

(3)  Carcinoma,  cicatricial  contraction,  diverticulum,  neoplasms,  of 
esophagus,  carcinoma  of  cardia. 

(4)  Reflex  vomiting,  as  in  pregnancy  and  sea-sickness. 

There  are  other  states  in  which  the  patients  are  either  unable  or 
iinwilling  to  swallow  food,  but  in  these,  feeding  by  the  tiibe  is  prefer- 
able to  rectal  feeding.  These  are  :  {a)  Inability  to  swallow  from 
coma,  delirium,  or  paralysis  of  the  muscles  of  deglutition ;,  post- 
diphtheritic paralysis.  {Jj)  Insanity,  refusal  of  food,  {c)  Total 
anorexia  (hysterical,  etc.). 

Intravascular  and  Hypodermic  Feeding. — In  1850  H odder  first 
practised  intravenous  injection  of  milk  in  cases  of  collapse  from  chol- 
era Asiatica.  T.  G.  Thomas  about  this  time  published  a  case  in 
which  y2  of  a  pint  of  milk  warmed  to  body  temperature  was  injected 
into  one  of  the  brachial  veins  with  the  result  of  saving  life. 
According  to  Oilman  Thompson  {loc.  cit.,  p.  383),  Fowler  has 
practised  intravenous  injection  of  peptone  and  has  also  given  six 
ounces  of  digested  beef  solution  in  this  manner.  There  seems  to 
us  no  physiological  reason  why  intravenous  or  even  intra-arterial 
feeding  should  not  be  practised  in  emergencies.  As  a  safeguard, 
however,  we  would  suggest  that  every  precaution  be  taken  to  have 
the  injection  absolutely  sterile,  and  composed  of  such  substances 
as  are  normal  to  the  blood,  such  as  serum-albumin,  sterile  plasma, 
defibrinated  fresh  sterile  blood.  Much  careful  experimenting  is 
required,  however,  before  we  can  be  justified  in  using  such 
methods  on  the  sick  human  being.  Intravenous  and  intra-arterial 
injections  of  warm,  sterile,  normal  salt  solutions  have  been  ex- 
tensively used  in  Asiatic  cholera  and  in  exhausting  hemorrhages. 
We  have  had  occasion  to  use  them  in  hematemesis  after  gastric 
ulcer,  with  the  conviction  that  life  was  saved  thereby. 

SubciitaneoiLS  Feeding. — In  1869  Menzel  and  Perco  injected  fats. 


2IO  DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 

albumin,  and  sugar  into  dogs  and  human  beings,  and  showed  that 
liquid  oils  were  resorbed  without  causing  local  or  general  reaction. 
They  injected  nine  gm,  of  oil  into  one  patient,  at  Billroth's  clinic, 
who  had  spinal  caries ;  a  swelling  as  large  as  a  silver  dollar  ensued, 
but  disappeared  entirely  in  thirty  hours  (Wiener  nied.  Wochenschr., 
1869,  No.  31). 

Attempts  have  been  made  in  the  human  being  with  injection  of 
defibrinated  calf's-blood  by  'LdindQ:nbergev [Wurteinberg.  vied.  Corre- 
spondenzbl.,  Bd.  xliv,  No.  20),  with  olive  oil  by  Krueg  (Referat  in 
Wien,  vied.  Wochenschr.,  1875,  No.  34),  with  olive  oil  and  milk  by 
Whittaker  [Schnidt's  Jahrb.,  Bd.  clxxvii,  Heft  i),  who  in  eight  sit- 
tings injected  124  gm.  in  one  day — in  all  he  made  68  injections. 
Karst  recommended  defibrinated  blood  {Berlin,  klin.  Wochenschr., 
1873,  No.  49).  Eichhorn  was  so  enthusiastic  with  his  injections  of 
milk-peptone  and  cod-liver  oil  that  he  believed  the  normal  nutri- 
tion of  an  animal  could  be  supplanted  by  this  method  ( Wien.  med. 
Wochenschr.,  188 1,  Nos.  32,  33,  and  34).  Leube  proved  that  oils 
injected  subcutaneously  were  actually  used  up  in  the  metabolism 
of  the  body  (Leube,  "  Verhandlung.  d.  XIV.  Congresses  f.  innere 
Medicin,"  1895).  In  spite  of  these  experiments  it  is  very  doubt- 
ful whether  subcutaneous  injections  of  nutritive  materials  can  ever 
be  utilized  to  even  supplement  normal  feeding.  The  caloric  value 
of  the  amounts  that  are  available  for  injection  is  comparatively 
insignificant,  the  method  quite  irritating,  and  in  progressed  sufferers 
hardly  justifiable. 


TABLES    OF    DIETETICS. 


211 


TABLES  OF  DIETETICS. 


APPROXIMATE  ANALYSES  OF  A  ^lAy.—{J/oss. 

(Height,  5  feet  8  inches;  weight,  148  pounds.) 


Pounds. 

Oxygen, 92.4 

Hydrogen,              ........  14. 6 

Carbon, 31-6 

Nitrogen, 4.6 

Phosphorus, 1.4 

Calcium, 2.8 

Sulphur, 0.24 

Chlorin, o.  12 


Pounds. 

Sodium, 0.12 

Iron, 0.02 

Potassium, 0.34 

^lagnesium, 0.04 

Silica, ? 

Fluorin, 0.02 


Total, 14S.00 


Landois  and  Stirling  give  the  following  table,  which  differs 
somewhat  from  the  other  tables  in  the  relative  proportion  of  fats 
and  starches.  An  adult  doing  a  moderate  amount  of  work  takes 
in  as  food  per  diem  : 


i                               ! 

c.        :        H.               N. 

0. 

120  gm.  of  albumin,  containing,      .... 

90  gm.  of  fats,  containing, 

330  gm.  of  starches,  containing,      .... 

64.18  ;     8.60      18.88 

70.20    ;      10.26          ... 
146.82         20.33          •    •    ■ 

28.34 

9-54 
162.85 

281.20     39.19  !  18.88 

200.73 

Add     744.11  gm.  of  O.  from  the  air  bv  respiration. 
"    2,818.00     "    of  H2O. 
"  32.00     "     of  inorganic  compounds  (salts). 

The  whole  is  equal  to  three  kilogm.  and  a  half  (seven  pounds), 
/.  e.,  about  one-twentieth  of  the  body  weight,  so  that  about  six  per 
cent,  of  the  water,  about  six  per  cent,  of  the  fat,  about  one  per 
cent,  of  the  albumin,  and  about  0.4  per  cent,  of  the  salts  of  the 
body  are  daily  transformed  within  the  organism. 

An  adult  doino;  a  moderate  amount  of  work  eives  off  in  g-m. : 


Water. 

C. 

H. 

N. 

0. 

By  respiration, 

By  perspiration, 

By  urine, 

330 

660 

1,700 

128 

248.8 
2.6 

9.8 

20.0 

3-3 
3-0 

0 

I5.8" 
3-0 

651-15 
7.2 
1       II. I 
12.0 

2,818 

281.2 

6.3 

18.8 

681.45 

212 


DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 


STANDARDS  FOR  DAILY  DIETARIES.— [Com/>i/ed  by  Atwaler.) 

Weights   of  nutrients    and   calories   of  energy   (heat    units)   in 
nutrients  required  in  food  per  day: 


Nutrients. 

Potential 

Energy. 

Protein. 

Fats. 

Carbo- 
hydrates. 

Total. 

Gm. 

Gm. 

Gm. 

Gl?i. 

Calories. 

Children  to  a  year  and  a  half,  . 

28 

37 

75 

140 

767 

(20-36) 

(30-45) 

(60-90) 

Children  of  two  to  six  years,    . 

55 

40 

40 

295 

1,418 

(36-70) 

(35-48) 

(100-250) 

Children  of  six  to  fifteen  years, 

75 

43 

325 

443 

2,041 

(70-80) 

(37-50) 

(250-400) 

Aged  women, 

80 

50 

260 

390 

1,859 

Aged  men, 

100 

68 

350 

518 

2,477 

Woman  at  moderate  work,  Voit, 

92 

44 

400 

536 

2,426 

Man  at  moderate  work,    Voit,  . 

118 

56 

500 

674 

3,055 

Man  at  hard  work,   Voit,  .    .    . 

145 

100 

450 

695 

3,370 

Man  at  moderate  exercise,  Play- 

119 

156 

51 

71 

531 

568 

701 

3,139 
3,629 

Active  labor,  Playfair,      .    .    . 

795 

Hard  labor,  Playfair,   .... 

185 

71 

568 

824 

3,748 

Woman  with  light  exercise,  At- 

80 

80 

300 

460 

2,300 

Man    with    light    exercise,  At- 

tvater,      .    .         

100 

100 

360 

460 

2,820 

Man  at  moderate  viorV,Atwater, 

125 

125 

450 

700 

3,520 

Man  at  hard  work,  Atzvater,     . 

150 

150 

500 

800 

4,060 

Man  at  moderate  work,  3fole- 

schott, 

130 

40 

550 

720 

3,160 

Man  at  moderate  work,  Wolff, 

120 

35 

540 

695 

3,032 

Table  of  analyses  made  by  Dujardin-Beaumetz,  showing  the 
proportion  of  nitrogen  present  and  also  the  combustible  carbon 
and  hydrogen  : 


Beef,  uncooked. 
Roast  beef,  .  . 
Calf's  liver,  .  . 
Foie  gras,  .  . 
Sheep's  kidneys. 
Skate,  .... 
Cod,  salted,  .  . 
Herring,  salted. 
Herring,  fresh. 
Whiting,  .  .  . 
Mackerel,      .    . 


Nitrogen. 

C  +  H 

Combustibles 

Calculated  as 

Carbon. 

3.00 

11.00 

3-53 
3-09 
2.12 
2.66 

17.76 
15.68 
65.58 
12.13 

3-83 
5.02 

12.25 
16.00 

3" 
1.83 

23.00 
21.00 

2.41 

3-74 

9.00 
19.26 

STANDARDS    FOR    DAILY    DIETARIES. 


213 


Table  of  analyses  showing  the  proportion  of  nitrogen  and  combustible  carbon  and 
hydrogen  [Contuttied] . 


Sole,       

Salmon, 

Carp, 

Oysters,     . 

Lobster,  uncooked, 

KcrCTS 

Millv,  cow's, 

Cheese  (Brie), 

Cheese  (Gruyere),         .    .        

Cheese  (Roquefort), 

Chocolate, 

Wheat  (hard  southern,  variable  average), 
Wheat  (soft  southern,  variable  average),  . 

Flour,  white  (Paris), 

Rye  flour,      .    .    .    , 

Winter  barley, 

Maize, 

Buckwheat, 

Rice, 

Oatmeal, 

Bread,  white  (Paris,  30  per  cent,  water). 
Bread,  brown  (soldiers'  rations  formerly). 
Bread,  brown  (soldiers'  rations  at  present) 
Bread  from  flour  of  hard  wheat,    .... 

Potatoes, 

Beans, 

Haricots,  dry, 

Lentils,  dry, 

Peas,  dry,      . 

Carrots, 

Mushrooms, 

Figs,  fresh, 

Figs,  dry,       

Plums, 

Coff"ee  (infusion  of  loo  gm.),     .    .        .    . 

Tea  (infusion  of  loogm. ), 

Bacon,  

Butter,  fresh, 

Olive  oil, 

Beer,  strong, 

Wine,        


Nitrogen. 


91 
09 

49 
13 
91 
90 
66 

93 
00 
21 
52 
00 
81 
64 

75 
90 

70 
20 

,80 

95 
08 

07 
20 
20 


4-50 
3-92 
3-87 
3.66 
0.31 
0.60 
0.41 
0.92 
0.75 


00 
29 
64 

05 
,1; 


C  4-  H 

Combustibles 

Calculated  as 

Carbon. 


12.25 
16.00 
12.10 

7.1S 
10.96 
13-50 

8.00 

35- 00 
38.00 

44-44 
58.00 
41.00 
39.00 
38.50 
41.00 
40.00 
44.00 
42.50 
41.00 
44.00 
29.50 
28.00 
30.00 
31.00 
11.00 
42.00 
43.00 
43.00 
44.00 
5-50 
4-52 
15-50 
34.00 
28.00 
9.00 
10.50 
71.14 
83.00 
98.00 

4-50 
4.00 


214 


DIETETIC   TREATMENT    OF    GASTRIC    DISEASES. 


THE   RELATIVE  VALUE  OF  FOODS.— {Scamme//.] 
(The  figures  represent  percentages.) 


As  Material 
for  the 
Muscles. 


As  Heat 
Givers. 


As  Food  for 
the  Brain 
and  Nerv- 
ous System. 


Waste. 


Wheat,  ... 
Barley,  -  .  . 
Oats,  .... 
Northern  corn, 
Southern  corn. 
Buckwheat,     . 

Rye, 

Beans,     .    .    . 
Peas,    .    .    . 
Lentils,   .    .    . 
Rice,    .    .    . 
Potatoes,      .    . 
Sweet  Potatoes, 
Parsnips,     .    . 
Turnips, 
Carrots,   ... 
Cabbage,     .    . 
Cauliflower,    . 
Cucumbers,     . 
Milk  of  cow. 
Milk,  human, 
Veal,   .... 
Beef,    .    .    . 
Lamb,      .    . 
Mutton, 
Pork,   .... 
Chicken,      .    . 
Codfish,  .    .    . 
Trout, 

Smelt,      .    .    . 
Salmon,  .    . 
Eels,    .... 
Herring,      .    . 
Halibut,  .    .    . 
Oysters,  .    .    . 
Clam,  .... 
Lobster,       .    . 
Eggs,  white  of. 
Eggs,  yolk  of. 
Butter,     .    .    . 
Artichoke,  .    . 
Asparagus, 
Bacon,     .    .    . 
Carp,    .... 
Cheese,    .    . 
Cherries, 
Chocolate,  .    . 
Cream,     .    .    . 
Currants,     .    . 
Dates,  fresh,  . 
Figs,    .... 
Ham,  .    . 


14.6 
12.8 
17.0 
12.3 
34-6 
8.6 

6.5 
24.0 

23-4 
26.0 

51 

1-4 

1-5 

2.1 

1.2 

I.I 

1.2 

3-6 

0.1 

5-0 

3-0 

17.7 

19.0 

19.6 

21.0 

17-5 
21.6 

16.5 

16.9 

17.0 

20.0 

17.0 

18.0 

18.0. 

12.6 

12.0 

14.0 

13.0 


1.9 
0.6 
8.4 
18.0 
30-8 
0.6 
8.8 

3-5 
0.9 


5-0 
35-0 


66.4 

S2.I 

50.8 
67-5 
39-2 
53-0 
75-2 
40.0 
41.0 

39-0 
82.0 

15-8 
21.8 

14-5 

4.0 
12.2 

6.2 

4.6 

1-7 
8.0 
7.0 

14-3 
14.0 

14-3 
14.0 
16.0 

1-9 
i.o 

0.8 
very  little 
some  fat 


very  little 


29.8 

100.  o 

19.0 

5-4 
62.5 

0.8 
28.0 
21.0 
88.0 

4-5 
6.8 

73-7 
57-9 
32.0 


1.6 
4.2 
3-0 
1. 1 

41 
1.8 

o-S 
3-5 
2-5 
1-5 
0.5 
0.9 
2.9 
1.0 

0-5 
1.0 
0.8 
1.0 

0-5 
1.0 

0-5 

2-3 

2.0 
2.2 
2.0 
2.2 
2.8 
2.5 
4-3 

5  or  6 

6  or  7 

3  or  4 

4  or  5 
3  or  4 

0.2 
2  or  3 

5  or  6 
2.8 
2.0 


14.0 
14.0 
13.6 
14.0 
14.0 
14.2 

14.8 

14. 1 

14.0 

9.0 

74.8 
67-5 
79-4 
90.4 

82.  s 

91-3 
90.0 
97.1 
86.0 
89.5 

65-7 
65.0 

63-9 
63.0 

64-3 
73-7 
80.0 
78.0 
75.0 
74.0 
75-0 
75-0 
74.0 
87.2 

79-9 
84.2 

Si-3 

'76.6 
93-6 
28.6 

78.3 
36-5 
76.3 

92.0 

81.3 
24.0 
18..7 
28.6 


3-4 
16.9 
16.9 

S-i 

8.1 

22.4 

4-3 

17.7 

19.0 

19-5 

3-4 

71 

6.3 

30 

3-9 

3-2 

0.5 
0.8 
0.6 


0.7 


I.I 

1-4 

10.7 

2-3 
15.0 


THE    RELATIVE    VALUE    OF    FOODS. 
THE  RELATIVE  VALUE  OF  FOODS  {Continued). 


215 


Articles. 


Horse-radish, 

Kidney,  .    .  . 

Lard,  .    .    .  . 

Liver,       .    .  . 

Onions,    .    .  . 

Pearl  barley,  . 

Pears,      .    .  . 

Pigeon,    ,    .  . 

Prunes,    .    .  . 

Radishes,    .  . 

Suet,    .    .    .  . 
Venison, 
Vermicelli, 

Whey,      .    .  . 


As  Material 
foi  the 
Muscles. 


O.I 
21.2 


26.3 

4-7 

0.1 

23.0 

3-9 


20.4 
47-5 


As  Heat 
Givers. 


4.8 

0.9 

100. 0 

3-9 

5-2 

78.0 

9.6 

1-9 
78.6 

7-4 

100.  o 

8.0 

38.0 

4.6 


As  Food  for 
the  Brain 
and  Nerv- 
ous System. 


I.O 

1-4 
1.2 
0.2 

2.7 

4-5 
1.0 

2.8 

1-7 
0.7 


Wate 


78.2 
76.5 

68.6 
93-8 
9-5 
86.4 
72.4 
13.0 
89.1 

68.8 
12.8 
94-7 


16.0 


7.6 
3-9 

1-3 


ATKINSON'S    TABLE    OF   DIGESTIBILITY    OF    NUTRIENTS    OF    FOOD 

MATERIALS. 


In  the  Food  Materials  Below. 


Of  the  Total  Amounts  of  Protein,  Fats,  and  Carbo- 
hydrates, THE  Following  Percentages 
were  Digested: 


Carbohydrates. 


Meat  and  fish,   .    . 

liggs, 

Milk, 

Butter,    .         ... 
Oleomargarine, 
Wheat  bread,     .    . 
Corn  (maize)  meal. 

Rice, 

Peas, 

Potatoes,     .... 
Beets, 


Practically  all 
88  to  100 


81  to  100 


86 

74 
72 


79  to  92 

96 
93  to  98 

98 

96 


99 
97 
99 
96 

92 
82 


PERCENTAGES    OF   NUTRITION   IN   VARIOUS   ARTICLES    OF   FOOD. 

{Moss.) 


Raw  cucumbers, 2 

Raw  melons, 3 

Boiled  turnips, 4/^ 

Milk, 7 

Cabbage, lYz 

Currants, 10 

Whipped  eggs,     .    ., 13 

Beets, 14 

Apples,      16 

Peaches, 20 

Boiled  codfish, 21 


Broiled  venison, 22 

Potatoes, 22; 

Fried  veal, 24 

Roast  poultry, .26 

Raw  beef, 26 

Raw  grapes, 27 

Raw  prunes, 29 

Boiled  mutton,      .         3° 

Oatmeal  porridge, 75 

Rye  bread, 79 

Boiled  beans, 87 


2l6 


DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 


TERCENTAGES  OF  NUTRITION  {Continued). 

Boiled  rice, ....  88  Boiled  bailey,  . 92 

Barley  bread, 88  Butter, 93 

Wheat  bread, 90  Boiled  peas, 93 

Baked  corn  bread, 91  Raw  oil, 96 

The  average  percentage  of  the  different  food  classes  needed  to 
sustain  a  man  in  perfect  health  is  given  in  Kensington  Museum 
"  Handbook  on  Food  "  : 

Per  cent. 

Water, Si. 5 

Albuminoids  or  flesh-formers, ...  3.9 

Starches  and  sugars, 10. 6 

Fat, 3-0 

Salt  (NaCl), 0.7 

Phosphates,  pota>h  salts,  etc., 0.3 

AN  IDEAL  RATION  WITH  SOLID  ¥OOT>.—{Mrs.  E.   H.   Richards.) 


Amount. 

Proteid. 

Fat. 

Carbohydrates 

M.\TEKIAL. 

Calories 

Gm. 

Ozs. 

Gm. 

Ozs. 

Gm. 

Ozs. 

Gm. 

Ozs. 

Bread,  .... 

453-6 

16 

31-75 

1. 12 

2.26 

0.08 

257.28 

9.04 

1,206.82 

Meat,    .... 

226.8 

8 

34.02 

1.20 

11-34 

0.04 

243-72 

Oysters,    .    .    . 

226.8 

8 

12.52 

0.44 

2.04 

0.07 

70.01 

Breakfast  cocoa, 

28.3    ' 

I 

6.60 

0.23 

7 -.50 

0.26 

9.60 

0.34 

135-42 

Milk 

II3-4 

4 

3-63 

0.13 

4.42 

0.16 

4.88 

0.17 

75-55 

Broth,  .... 

453-6 

16 

18.14 

0.64 

18.14 

0.64 

9072 

3.20 

613.21 

Sugar,  .... 

28.3 

I 

27.36 

0.96 

112. 17 

Butter,      .    .    . 

14.17 

% 

0.14 

12.27 

118.62 

Total,   .    . 

•    -1 

106.80 

. 

57-97  j  •    ■    • 

389.84 

2,575-52 

The   following   table   is    a   fair    average   work    ration    in    round 
numbers,  based  on  such  data  as  those  in  the  other  tables : 

ESTIMATED  WORK    RATION,   MAXIMUM  AND    MINIMUM.— 

{Mrs.  E.   If.  Richards). 

For  One  Day. 

T^         -J  (       125 

Proteid,  gm., |      ^^^ 

F^t,  gm I      '^5 

Carbohydrates,  gm., -;      ^ 

Calories, -^^^^00 

About  30  gm.  of  salts  should  be  added  to  this  (Landois).     The 
bare  subsistence  ration  is  much  less,  as  follows  : 

ESTIMATED  LIFE  RATION.— (.1/;-^.  E.  H.  Richards.) 

For  One  Day.  For  One  Day. 

Proteid,  gm 75  Carbohydrates,  gm.,     .    .      325 

Fat,  gm.,  ......        40  Calories, 2,000 


TABLE    OF    ENERGY, 


217 


It  will  be  observed  that  the  totals  are  somewhat  less  in  this  diet 
than  those  of  the  preceding  table,  which  is  designed  for  a  working 
man  who  is  developing  more  calories. 

TABLE  OF  ENERGY. 

Estimated  in  Foot  Tons  instead  of  Calories. — (  Veo.) 

Energy  developed  by  one  ounce  of  the  following  foods  when 
oxidized  in  the  body  : 


Food  Stuff. 


Beef  (best  quality) ,  uncooked,  .  .  . 
Meat  (served  to  soldiers),  uncooked. 
Beef  (fattened),  uncooked,      .    . 

Meat,  cooked, 

Corned  beef  (Chicago), 

Salt  beef, 

Salt  pork, 

Fat  pork, 

Dried  bacon, 

Smoked  ham, 

Whitefish, 

Poultry, 

Bread,    

Wheat  flour, 

Biscuit, 

Rice,      

Oatmeal, 

Maize, 

Macaroni, 

Millet, 

Arrowroot, 

Peas  (dried), 

Potatoes, 

Carrots, 

Cabbage, 

Butter, .    . 

Eggs, 

Cheese, 

Milk  (cow's),  new,       

Cream, 

Skimmed  milk, 

Sugar, 

Pemmican, 

Ale  (Bass's  bottled), 

Stout  (Guinness), 


With  Usual  Per- 
centages of  Water. 


Foot  Tons. 

48.5 

57-55 

96.0 

102.6 

124.0 

52.0 

71.6 

202.0 

292.3 

179.6 

44-3 

50-7 

87-5 

123.6 

173-3 
126.5 
130.0 
132.0 
122.7 

125.9 

116  4 

118. 9 

33-0 

14-3 

13.0 

344-5 
67-3 

149.9 
26.9 

109.2 
20.4 

126.4 

270.1 
30.0 
41-5 


One  Ounce 
Water-free. 


Fooi  Tons. 
199 

243 
280 
240 
217 
138 
166 
336 
346 
267 
209 
204 

147 
146 
189 
141 
154 
160 
146 
149 
138 
151 
141 

137 
158 
367 
265 

245 
225 

365 
181 
128 

293 
260 
360 


Prof   Egleston's  standard  of  nutrition  is  high.     He  places  the 
daily    allowance    of   nutritive    material    at    700    gm.,    divided    as 
follows:    Carbohydrates,   400    gm. ;    fats,    150    gm. ;    proteid,    150 
gm., — yielding  in  all  3650  calories. 
15 


2l8 


DIETETIC    TREATMENT    OF    GASTRIC    DISEASES. 


PERCENTAGE  COMPOSITION  OF  EDIBLE  PORTIONS  OF  GARRISON 
RATION.— (Ca/z-rtw  C.  E.   Woodruff,  M.D.,  Asst.  Surgeon,  U.  S.  A.) 


Water. 


Fats. 


Carbo- 
hydrates. 


Salts. 


Energy 

Calories, 

per  lb. 


Bacon,  fat 

Beans, 

Pork,  salt  and  fat,  .  . 
Sugar,  ground,  .... 
Sugar,  brown  issue,  .    . 

Flour,      

Beef, 

Potatoes, 

Onions, 

Oatmeal, 

Cornmeal, 

Canned  apples,  .... 
Dried  apples,  .... 
Tapioca  or  corn-starch, 

Butter, 

Syrup, 

Lard, 

Rice, 

Canned  corn,  .... 
Canned  tomatoes,  .  .  . 
Macaroni  and  vermicelli, 
Milk,  fresh,  .  .  .  . 
Milk,  condensed,   .    .    . 

Peas, 

Raisins, 

Cheese, 

Prunes, 

Cabbage,     

Ham, 

Apricots,  canned,  . 

Barley, 

Chocolate, 

Sausage,      

Oysters, 

Salmon,  canned,     .    .    . 

Crabs,      

Crackers, 


20.  o 
12.6 
12. 1 

2.0 

30 

12.5 

55-0 

78.9 

87.9 
7.6 
15.0 
83.2 
25.0 
2.0 
10. 5 

43-7 
12.0 
12.4 

81.3 
96.0 

131 
14. 1 
25.0 
12.3 
40.0 
35-0 
30.0 
92.0 

41-5 
50.0 


12.0 
41.2 

87.1 
6-v6 


8.00 
23.10 

0.90 


11.00 

17.10 

2.10 

1-4 
15.10 
9.20 
0.20 
0.90 

1. 00 

0.60 

7-4 
2.80 
0.80 
9.00 
0.843 
17.00 
26.70 
0.40 

33-00 
2  50 
2.10 

16.7 
2.00 

13.00 

20.00 

13.80 
6.00 

21.60 

15-0 

10.:^ 


69-5 
2.0 

82.8 


i.o 

27.0 
0.1 
0-3 
7-1 
3-8 
0.4 
1.8 

85.0" 

"83-4" 
04 
I.I 
0.4 

03 
0.802 

II.O 

1-7 
22  o 

'  0.6* 
39-1 

2.7 
500 
42.8 

1.2 

13-4 
1.0 

94 


59-2 

97.8 
96.5 
74-9 

17.9 
10. 1 
68.2 
70.6 
15-9 
71-5 
97.8 

05 

55-0 

79-4 
13.2 

2.5 
76.8 

1.069 
44.00 
56.40 
24.00 

5.00 
12.0 

S-5 

30.0 
.76.0 
10.  o 

3-7 


70.5 


2-5 

31 
4.2 
0.2 
05 
05 
0.9 
1.0 
0.6 
2.0 
1.4 
0-3 
1-4 
0.2 

3-0 

2-3 
4.0 
0.4 
0.6 

0-3 
0.8 
0.164 

3-0 
29 
0.6 

5-0 
0.6 
I.I 

2.7 
0.6 

30 
4.0 
2.2 
2.0 
1-4 


3,080 
1,615 
3,510 
1,820 

1,795 
1,644 
1,460 

375 
225 
1,850 
1,645 
315 
1,418 
1,820 

3,615 
1,023 

3,570 
1,630 

345 

80 

1,406 

418 
1,595 
1,565 

440 
1,600 

140 

155 
1,960 

460 
1,800 
2,650 
2,065 

230 

965 

526 

1,900 


Church  furnishes  the  following  table  showing  the  number  of 
tons  which  it  is  calculated  could  be  raised  through  the  height  of 
one  foot  by  the  complete  combustion  of  a  single  pound  of  each 
kind  of  food.  In  the  body  only  about  a  fifth  of  this  energy  would 
develop  work,  the  rest  going  into  heat  production. 


I  pound  beef  fat 
I  pound  oatmeal 
I  pound  gelatin 
I  pound  lean  beef 
I  pound  potatoes 
I  pound  milk 
I  pound  ground  rice, 


raises  5,649  tons  I  foot  high. 

2,439  " 

2,270  "  " 

885  " 

618  " 

390  '■ 

2,330  " 


CHAPTER  II. 
DIETETIC    KITCHEN.     DIET    LISTS. 

In  the  following  we  give  the  diet  orders  of  Penzoldt,  which  agree 
essentially  with  those  mentioned  by  Leube,  but  have  this  advantage 
over  the  latter,  that  they  contain  at  the  same  time  the  permissible 
quantities  of  each  article  of  food,  and  are  also  expanded  in  other 
directions. 

The  following  diet  list,  consisting  of  four  different  kinds  of  diet, 
is,  like  that  of  Leube,  especially  intended  to  be  a  basis  for  a  mild 
dietetic  treatment  in  cases  of  diseases  of  the  stomach  in  general  (the 
so-called  ulcer  cure  of  Leube).  By  means  of  a  gradual  transition 
from  a  very  light  to  a  stronger  and  richer  diet,  it  endeavors  not  to 
tax  the  diseased  organ  in  the  beginning,  and  gradually  to  accustom 
it  to  increased  service. 

It  is  self-evident  that  this  diet  list  may  not  with  impunity  be 
extended  in  the  same  manner  to  all  diseases  of  the  stomach. 
According  to  the  state  of  the  secretion,  the  peristalsis,  and  of  sen- 
sation, other  problems  concerning  the  diet  may  arise.  We  will 
revert  to  the  special  details  of  the  several  forms  of  disease  when 
we  come  to  them.  It  is  necessary  only  to  give  the  principal  rules 
for  the  chief  types  of  diseases  of  the  stomach  in  this  chapter. 

PENZOLDT' S  DIET  ORDERS  FOR  GRADUAL  TRAINING   OF  THE 
DIGESTIVE  CAPACITY. 

FIRST   DIET  (ABOUT   TEN    DAYS). 

Largest 
Foods  or  Drinks.     Quantity  at  .       Preparation.  Character.  How  to  be  Taken. 

One  Time,      i 


Bouillon.  I  250  gm.,   j^    To  be  made  from    Lean,   very   little    Slowly. 

I     liter.  beef.  salt,  or  none  at 

all. 

I 

Cow's  milk.  250  gm.,   y^    Well   boiled,    or    Pure    milk,    or    Eventually    with 

liter.  [     sterilized  eventually      y(       a  little  tea. 

1      (Soxhlet's    ap-       lime-water   and 
paratusj.  ,      ^  milk. 

i 

219 


220 


DIETETIC    KITCHEN. 


Penzoldt's  Diet  Orders  for  Gradual  Training  of  the  Digestive  Capacity. 
First  Diet  (about  Ten  Days)  [Continued). 


Foods  or  Drinks. 

Largest 

Quantity  at 

One  Time. 

Preparation. 

Character. 

How  TO  BE  Taken. 

liggs- 

One  or  two. 

Very  soft,  merely 
wanned  or  raw. 

Fresh. 

If  raw,  stir  into 
the  warm,  not 
boiling,  bouil- 
lon. 

Meat  solution    30-40  gm. 
(Leube- Rosen- 
thal's).                1 

See  Dietetic  Kit- 
chen. 

It  may  have  only 
a  faint   odor  of 
bouillon. 

By  teaspoonfuls 
or  stirred  up  in- 
to bouillon. 

Cakes    (Albert 
biscuits). 

Six. 

Without  sugar. 

Not  soaked  or 
softened,  but  to 
be  well  masti- 
cated and  in- 
salivated. 

Water. 

yk  liter. 

Ordinary  or   nat- 
ural carbonated, 
containing    a 
little      carbonic 
acid     (Selters), 
Saratoga  Vichy, 
Londonderry 
Lithia,  Poland. 

Not  too  cold. 

SECOND   DIET   (ABOUT   TEN    DAYS). 


Foods  or  Drinks. 

1 
Largest 

Quantity  at          Preparation. 

One  Time. 

Character. 

How  to  be  Taken. 

Calf's  brain. 

100  gra.             Boiled. 

To  be  freed  from 
all    membranes 
and  fiber. 

Preferably  in  the 
bouillon. 

Sweetbread 
(thymus  gland). 

100  gm. 

Boiled. 

Similar  to  above, 
especially  to  be 
peeled  carefully. 

Similarly  to 
above. 

Pigeons. 

One. 

Boiled. 

Only  young  ones, 
without      skin, 
tendons  and  the 
like. 

Similarly  to 
above. 

Chickens. 

One,  the  size 
of  a  pigeon. 

Boiled. 

Like    above     (no 
fattened    chick- 
ens). 

Similarly  to 
above. 

Raw  beef. 

100  gm. 

Finely    chopped 
or  scraped, 
with     a     little 
salt. 

To  be  taken  from 
the  fillet  (tender- 
loin). 

To  be  eaten  with 
crackers. 

PENZOLDT  S    DIET    ORDERS. 


221 


Penzoldt's  Diet  Orders  for  Gradual  Training  of  the  Digestive  Capacity.- 
Second  Diet  (about  Ten  Days)  {Continued'). 


Largest        I 
Foods  or  Dkinks.  ;    Quantity  at  I       Preparation. 
One  Time. 


Character. 


How  TO  BE  Taken. 


Raw    beef    sau-    loo  gm. 
sage. 


Tapioca. 


30  gm. 


Without       addi-    A  little  smoked.     !  Similarly  to  pre- 
tions.  ceding. 


Cooked  to  a 
homogeneous 
gruel  with 
milk. 


THIRD    DIET   (ABOUT    EIGHT    DAYS). 


Foods  or  Drinks. 

Largest 

Quantity  at 

One  Time. 

Preparation. 

Character. 

How  to  be  Taken. 

Pigeon. 

One. 

To  be  fried  with 
fresh  butter, 
not  too  much. 

Only  young  ones, 
without      skin, 
etc. 

Without  sauce. 

Chicken. 

One. 

Like  above. 

Like  above. 

Like  above. 

Beefsteak. 

100  gm. 

With  fresh   but- 
ter,   half    raw 
(English). 

The    meat    from 
thefiilet,  or  ten- 
derloin,    well 
pounded. 

Like  above. 

Ham. 

100  gm. 

Raw,  scraped 
fine. 

Smoked,    not 
strong,   without 
bones,    the    so- 
called  "  Lachs- 
schinken." 

With  wheat 
bread. 

French  roll,  toast, 
or    Freiberg 
pretzel. 

50  gm. 

Baked  crisp. 

Stale    (rolls    and 
the  like.) 

To  be  chewed 
very  carefully 
and  to  be  well 
salivated. 

Potatoes. 

50  gm. 

a.  As  puree,  be- 
ing     forced 
through      a 
strainer. 

b.  As  salt   pota- 
toes, mashed. 

The  potatoes  must 
be        mealy , 
crumbling  when 
mashed. 

Cauliflower. 

50  gm. 

To  be  cooked  in 
salt    water    as 
vegetables. 

Only  the    "flow- 
ers "  to  be  used. 

222 


DIETETIC    KITCHEN. 


Penzolut's  Diet  Orders  for  Gradual  Training  of  the  Digestive  Capacity 

(^Continued'). 

FOURTH  DIET  (ABOUT  EIGHT  TO  FOURTEEN  DAYS). 


Largest 
Foods  or  Drinks.     Quantity  at 
One  Time. 


Venison. 


Partridge. 


Roast  beef. 


Fillet. 


loo  gm. 


Preparation. 


Roast. 


How  to  be  Taken. 


Saddle,  hung,  not 
gamy,  without 
high  flavor. 


One. 


Roast,      without 
lard. 


ICO  gm. 


ICO  grb. 


Fried  until  red. 


Young  birds,  with 
skin,  tendons, 
feet ,  etc.,  re- 
moved, after 
having  hung  in 
pure  cold  air 
for  twenty- four 
hours. 


From  well-fed  I  Warm  or  cold, 
cattle,  pounded. 


In  same  manner 
as  the  above. 


In  same  manner    In  same  manner 
as  the  above.  as  the  above. 


Veal. 


Caviar. 


Asparagus. 


Rice. 


ICO  gm. 


Roast. 


Saddle  or  leg.        i  Finely  cut 


Pike.  ]        I 

Trout.  J 


Boiled  in  salt 
water  without 
any  additions. 


Carefully  remove 
the  bones. 


50  g™- 


Russian  Caviar 
with  but  a  little 
salt  in  it. 


50  gm- 


Boiled. 


Soft,  without  the 
hard  portions. 


50  gm. 


As  gruel,  forced 
through  a 
strainer. 


Soft,  boiling  rice.    Likewise, 


In  fish  sauce. 


With   a  little 
melted  butter. 


Poached  eggs.  Two  eggs. 


With   a    little 
fresh  butter. 


With  salt. 


Egg    souffle 
(Auflauf). 


Two  eggs. 


With    about    20 
gm.  sugar. 


Must  rise  well. 


To    be    eaten    at 
once. 


Stewed  fruits. 


Sogm. 


Fresh  boiled, 
forced  through 
a  strainer. 


Freed  of  all  skins 
and  seeds. 


Red  wine. 


100  gm. 


Light,  pure  Bor- 
deau.x,  or  reli- 
able California. 


Or  any  similar 
kind  of  pure  red 
wine. 


Slightly  warmed. 


All  of  these  foods  should  be  prepared  according  to  directions 
given  in  the  "  Dietetic  Cooking-." 


DIET    LISTS.  .  223 

DIET  LIST  OF  EWALD  FOR  CHRONIC  GASTRITIS. 

8  A.M. — 150  to  200  gm.  of  tea,  with  100  gm.  of  stale  wheat  bread,  toast,  or 

Zwieback. 
10  A.  M. — 50  gm.  of  wheat  bread,  10  gm.  of  butter,  50  gm.  of  cold  meat  or  ham, 

and  either  one  glass  of  light  wine  or  ^  of  a  liter  of  milk. 

2  P.  M. — 150  to  200  gm.  of  water,  milk,  or  bouillon  of  white  meats;   100  to  125 

gm.  of  meat  or  fish,  30  to  100  gm.  of  vegetables,  80  gm.  compote. 
4.30  p.  M. — y^  of  a  liter  of  warm  milk,  chocolate,  or  one-half  milk  and  one-half 
coffee. 

7  to  8  p.  M. — 306  gm.  of  soup,  50  gm.  of  wheat  bread,  10  gm.  of  butter. 

10  p.  M. — Occasionally  50  gm.  of  wheat  bread,  biscuit,  or  Zwieback ;  one  cup 
of  coffee. 

Boas  gives  two  lists  ;  the  following  contains  the  better  and  richer 

diet: 

Calories. 

8  A.  M. — 200  gm.  of  milk,  with  40  gm.  of  cocoa  and  30  gm.  of  sugar,     .  462 

50  gm.  of  cakes,  or  50  gm.  of  Zwieback,  either  one, 187 

10  A.  M. — 50  gm.  of  wheat  bread  with  30  gm.  of  butter, 343 

100  gm.  of  calf's  brain  (or  100  gm.  of  sweetbread,  90  calories),    .    .  140 
Or  100  gm.  of  broiled  pike,  71.75  calories. 

12  M. — Soup  of  30  gm.  of  tapioca,  10  gm.  of  butter,  i  ^gg, 282 

100  gm.  of  noodles,      352 

Or  100  gm.  of  spinach,  165.0  calories;  100  gm.  of  bean  puree, 
193  calories ;  100  gm.  of  carrots,  40.0  calories ;  50  gm.  of 
potato  puree,  63.7  calories. 

100  gm.  of  breast  meat  of  young  chicken, 106.4 

100  gm.  of  veal  cutlets  (250  calories),  or  in  its  place  too  gm.  of 

broiled  veal,  pigeon,  venison,  or  fish. 
100  gm.  of  farina  or  omelette,  or  egg-pancake, 288 

3  p.  M. — 100  gm.  of  milk,  with  20  gm.  of  sugar,  flavored  with  tea,   .    .    .  147 

25  gm.  of  cakes, 93.5 

7P.M. — 50  gm.  of  wheat  bread,  130  gm.  of  butter, 3^13 

50  gm.  of  scraped  raw  beef, 459-5 

3203.4 

HEMMETER'S  DIET  LIST  FOR  CHRONIC  GASTRITIS  WITH  UNIM- 
PAIRED MOTILITY  AND  INTESTINAL  DIGESTION. 

Also  Available  for  Lowered  Nutrition  where  Digestive  Functions  are 

Normal. 

7.30  A.  M. — If  the  bowels  are  regular,  ^  of  a  pint  of  hot  normal  saline  solution. 
If  the  bowels  are  constipated,  a  pint  of  cold  Saratoga  Vichy,  Bedford 
Magnesia  Spring,  or  plain  cold  water. 

Calories. 
Breakfast,  8  A.  m. — y^  ounces  or  100  gm.  of  farina,  boiled  with  milk,        127 
Or  100  gm.  of  cerealin,  boiled  with  milk. 
Or  100  gm.  of  breakfast  wheat  (strained),  boiled  with  milk. 


224  DIETETIC    KITCHEN'. 

Calories. 

One  soft  boiled  t^<g 8° 

Two  ounces  of  wheat  bread,  toasted 156 

One  ounce  of  best  fresh  butter 212 

One  cup  of  wheat  coffee  (made  of  100  gm.  of  roasted  choice  wheat, 
250  c.c.  of  boiling  water,  and  1 50  gm.  of  milk).    Instead  of  this 

the  same  portions  of  tea  and  milk  or  cocoa  can  be  used,  .    .    .  ico 

Sugar,  10  gm.  (2j^  drams) 4° 

The  farina  or  cerealin  will  taste  better  if  eaten  with  a  roasted  apple. 
As  the  digestive  power  improves,  the  &g%  is  presented  in  form  of 
omelette,  or  poached,  on  toast. 

Calories, 

10.30  A.  M. — 100  gm.  of  scraped  ham  (3J.3  ounces) 120 

30  gm.  of  crackers  or  toast  (one  ounce), 107 

226  gm.  or  eight  ounces   of  broth.     Instead  of  broth,  milk,  kefir, 

and  matzoon  may  be  permitted  in  the  same  quantity,    ....        306 
Dinner,  i  p.  m. — Soup  made  of  250  gm.  or  eight  ounces  of  bouillon,  30 
gm.  or  one  ounce  of  rice  or  tapioca,  ten  gm.  or  2j^    ounces  of 
butter,  and  one  egg, --        282 

In  case  of  much  weakness  and  emaciation,  ^  of  a  tablespoonful 
of  somatose  should  be  added. 

The  patient  must  not  be  aware  of  the  addition  of  artificial  foods. 

Calories. 
120  gm.  of  breast  meat  of  broiled  fowl 228 

Or  scraped  tenderloin  formed  into  patties  and  broiled  ; 

Or  steamed  or  broiled  bluefish,  trout,  white  or  yellow  perch  ; 

Or  broiled  rockfish,  or  sweetbreads. 

50  gm.  or  two  ounces  of  potato  puree 637 

100  gm.  or  3)^ounces  of  carrots,  steamed, 40 

Or  TOO  gm.  of  puree  of  beans  or  peas  ; 

Or  100  gm.  of  strained  tomato  puree. 
TOO  gm.  of  finely  divided  spinach. 
One  cup  custard  made  of  two  eggs, 160 

Or  instead  of  this,  100  grs.  of  sherry  gelatin,  or  stewed  apples, 
or  plums,  or  rice  in  form  of  very  light  pudding  made  with 
slices  of  apple,  no  raisins. 
One  glass  (100  gm.  or  3)^  ounces)  of  Hungarian  Tokay  (J.  Palug- 

yay  &  Sons,  Pressburg) 50 

Instead  of  the  meats  given,  the  patient  may,  for  a  change,  be 
allowed  broiled  pigeon  or  venison,  which  must  not  be  gamy;  also 
meat  dumplings  of  scraped  beef,  scraped  pork  made  into  balls  with 
bread  crumbs.  Zwieback  crumbs,  o.^^,  and  butter,  cooked  in  bouil- 
lon, and  a  separate  sauce  is  made  and  flavored  with  scraped  sar- 
delles. 


DIET    LISTS. 


225 


Calories. 
3  P.  M. — One  cup  of  chocolate  made  with  30  gm.  or  i  ounce  of  breakfast 

cocoa,  or  v.  r^Iering's  Kraft-chocolate,  and  Yz  of  a  pint  of  milk,       135.5 
30  gm.  of  crackers,    coffee-cake  without  grated    nuts,    cinnamon 

shortcake  with  but  the  faintest  trace  of  cinnamon,       107 

If  the  sweet  chocolate  is  not  agreeable,  plain  milk,  or  a  glass  of 
light  Rhine  wine  with  crackers,  is  allowable.  Coffee  in  small 
quantities  may  be  added  to  the  milk  at  this  hour. 

Calories. 
Supper,  6.30  p.  m. — Broiled,  panned,  or  raw  oysters,  240  gm.  or  eight 

ounces /o 

If  there  is  sub- or  anacidity,  the  addition  of  a  little  grated  horse-radish, 
lemon  juice,  or  catsup  to  the  raw  oysters  should  not  be  forbidden. 

Crackers,  two  ounces  or  60  gm., 

Butter,  one  ounce  or  30  gm 

yi  of  a  pint  of  reliable  Rhine  wine, 

Ox  Yz  oi  2l  pint  of  imported  beer,  >^  of  a  pint  of  tea  and  milk. 
Instead  of  the  oysters,  little-neck  clams,  fresh  scraped  beef, 
finely  cut  roast  lamb  or  beef,  cold,  smoked  chipped  beef, 
or  smoked  tongue  will  answer. 
Note. — If  the  gastritis  is  evidently  due  to  abuse  of  alcohol,  the  wines  must  be 
excluded. 

BILL   OF  FARE    FOR    CHRONIC    CATARRH   OF  THE   STOMACH,  WITH 
THE  DIGESTION  OF  THE  STOMACH  ONLY  REDUCED.— ( ^F^^^^fe) 


107 
212 

50 


Morning  : 

150  gm.  of  pepton  cocoa, 

25  gm.  of  butter  (on  toasted  roll),  . 
Forenoon : 

I  soft  egg, 

Noon  : 

200  gm.  of  oatmeal  soup, 

150  gm.  of  fowl, 

200  gm.  of  carrot, 

Afternoon : 

150  gm.  of  pepton  cocoa, 

25  gm.  of  butter  and  Albert  or  ban- 
quet crackers, 

Evening  : 

i  egg, 

100  gm.  of  scraped  ham, 

100  gm.    of  macaroni,    with   toasted 

bread  crumbs,  .    .         

During  the  Day: 

200  gm.  of  wine, 

75  gm.  of  toast, 


8.00 
0.18 

6.00 


12.50 

28.00 

2.14 


8.00 
0.18 


6.00 

2vOO 


9.00 


CaK  BO- 
HYDRATE. 


Alcohol. 


9.00 


Total, 117.20 


6.0 
20.8 

5-0 

0.3 

13-5 

0.4 

6.0 
20.8 


5-u 
8.0 


1-5 


94.6 


Calories  about. 


480 


7.50 
o.i; 


18.00 

1.80 

16.30 

7-5° 
0.15 


76.70 

6.00 
63.90 


16.0 


2^6.01 


16.0 


970 


Entire  combustion  value  about  2440  calories. 


226  DIETETIC    KITCHEN. 

BILL  OF  FARE  FOR  ATROPHIC  CATARRH.— (JVege/e-FensoM.) 


Albumin. 

Fat. 

Carbo- 
hydrate. 

Alcohol. 

Morning: 

150  gm.   of  maltoleguminose  cocoa, 

Forenoon : 

150  gm.  of  wine, 

20  gm.  of  butter  (on  toasted  bread). 

Noon  : 

100  gm.  of  maltoleguminose  soup,    . 

100  gm.  of  scraped  beefsteak,   .    .    . 

100  gm.  of  mashed  potatoes,      .    . 
10  gm.  of  malt  extract,     ..... 
Afternoon : 

I  cup  of  tea  (with  toast), 

20  gm.  of  butter, 

30  gm.  of  honey, 

Evening: 

250  gm.  of  rice  mush, ; . 

During  the  Day  : 

75  gm.  of  toast  (or  toasted  bread),    . 
10  o'clock  at  Night  : 

250  gm.  of  milk,      .    .             .... 

10  gm.  of  cognac  brandy,     .... 

6.00 

0.15 

2.60 

20.00 

3.10 

0.50 

0.15 
0.40 

22.00 

9.00 

8.70 

4.00 
16.60 

O.IO 

6.00 
0.50 

16.60 

8.25 
1.50 
9-30 

13-50 

4.00 
0.12 

6.20 
21.30 

5-5° 

0.12 
22.00 

71.00 

63.90 

12.00 

12.0 
7.0 

Total, 

72.70 

62.85 

219.64 

19.0 

Calories  about, 

300 

580 

920 

130 

Entire  combustion  value  about  1 930  calories. 


BILL  OF  FARE  FOR  ATONY  OF  THE  STOMACH,  WITH  GASTRIC 
DIGESTION  REDUCED.  — (IVeo-e/e.) 


Morning  : 

150  gm.  of  leguminose  cocoa, 

50  gra.  of  cream, 

Forenoon : 

I  soft  egg, 

20  gm.  of  toast,   ...... 

Noon  : 

100  gm.  of  scraped  beefsteak, 
200  gm.  of  mashed  potatoes, 
20  gm.  of  malt  extract,      .    . 
Afternoon  : 

150  gm.  of  leguminose  cocoa, 
50  gm.  of  cream,    ..... 

Evening  : 

250  gm.  of  tapioca  pulp,     .    .    . 
15  gm.  of  diastase  malt  extract. 


Albumin. 


6.0 
1.8 

6.0 
2.5 

17. 1 
4.2 
i.o 

6.0 
1.8 

12.0 
0.8 


Fat. 


4.0 
13-3 

5-0 
0.4 

6.0 

2.7 


4.0 

13-3 
8.0 


Carbo- 
Hyukate. 


135 

1.8 


15.0 


42.6 

II. o 


13-5 
1.8 


II. o 

9.0 


Alcohol. 


DIET    LISTS. 


227 


Bill  of  Fare  for  Atony  of  the  Stomach,  with  Gastric  Digestion 
Reduced. — (  Wegele)  [Continued). 


Albumin. 

Fat. 

Carbo- 
hydrate. 

ALCOHOL. 

During  the  Day: 

50  gm.  of  toast, 

6.0 

6.4 

I.O 

7.2 

35-0 
9.6 

10  o'clock  at  Night: 

200  gm.  of  milk, 

10  gm.  of  cognac, 

'6.9 

Total, 

71.6 

64.9 

•    163.8 

6.9 

Calories  about, 

290 

600 

670 

50 

Total  combustion  value  about  16 10  calories. 

At  noon,  of  course,  other  kinds  of  meat  could  be  chosen,  such  as 
fowl  or  game;  likewise  at  night  rice  or  thick  gruel. 

With  fermentation  of  the  stomach,  however,  the  following  bill  of 
fare  had  best  be  used  after  a  few  days : 

Morning  : 

100  gm.  of  scraped  ham  (can)  or  smoked  meat,  and  20  gm.  of  bread  crust. 
Forenoon : 

One  soft  egg  and  20  gm.  of  bread  crust  or  toast. 
Noon: 

JOG  gm.  of  scraped  beefsteak  and  scrambled  eggs  (two). 
Afternoon : 

Same  as  forenoon. 
Evening  : 

Same  as  noon. 

Two  clysters  of  ^  to  lyi  per  cent,  common  salt  solution. 

HEMMETER'S  DIETARY  FOR  ANACID  DILATATION. 

Calories. 
7.30  A.  M. — Lavage  with  NaCl  solution  or  a  decinormal  solution  of  HCl. 

8  A.  M. — Cerealin  with  cream,  150  gm., 395 

Mosquera  beef  chocolate,  200  gm., 140 

Malt  extract,  10  gm 24.5 

10  A.  M. — Toast  or  aleuronat  bread  (see  dietetic  directions),  60  gm 135 

Butter,  20  gm 163 

12  M. — Boiled  round  of  beef,  150  gm 440 

Mashed  potatoes,  50  gm 63 

Spinach  or  carrots,  100  gm., 165.5 

In  place  of  these,  purees  of  peas,  beans,  lentils,  or  turnips  are 
allowed. 

Omelette  souffle,  100  gm 244 

3  P.  M. — 100  gm.  of  tea,  50  gm.  of  Albert  biscuits,  10  gm.  of  milk,   .    .    .  254 


DIETETIC    KITCHEN. 


Calories. 

7  p.  M. — loo  gm.  of  scraped  ham  in  omelette 244 

Or  60  gm.  of  scraped  ham  (262  calories). 

200  gm.  of  farina  with  milk 432 

60.  gm.  of  toast,  20  gm.  of  butter, 29S 

9.30  p.  M. — Milk,  300  c.c 202 

Two  ounces  of  banquet  crackers  or  Albert  biscuits 200 

Or  in  place  of  the  milk  a  glass  (two  ounces)  of  approved  Tokay 
or  Malaga. 

BILL  OF  FARE  FOR  ATONY  OF  THE  STOMACH,  WITH  THE  PRODUCTION 
OF  HYDROCHLORIC  ACID  SUSTAINED  OR   INCREASED.— ( fr<.v/^.) 


Albumin. 

Fat. 

Carbo- 
hydrate. 

Alcohol. 

Morning  : 

150  gm.  of  pepton  cocoa, 

50  gm.  of  cream, 

Forenoon : 

30  gm.  of  French  roll,    , 

50  gm.  of  ham, 

8.0 
1.8 

30 

12.5 

6.0 

21.0 
4.2 

8.0 
1.8 

21.0 
9.0 

6.0 
13-3 

0.2 
4.0 

5-0 

8.0 
2.7 

6.0 
13-3 

8.0 
6.6 

1.6 

7-5 
1.8 

20.0 

42.6 

7-5 
1.8 

'28.6 

3-3 
41.0 

I  esre 

Noon  : 

120  gm.  of  roast  meat, 

200  gm.  of  mashed  potatoes,      .    .    . 
Afternoon : 

150  gm.  of  pepton  cocoa, 

50  gm.  of  cream, 

Evening: 

120  gm.  of  cold  roast  meat,    .... 

2GO  cm.  of  rice, .    . 

10  o'clock  : 

100  gm.  of  wine, 

7.8 

During  the  Day  : 

50  gm.  of  toast, 

6.5 

Total, 

102.8 

74-7           I59-I 

7.8 

Calories  about, 

420 

700       1       640 

55 

Total  combustion  value  about  1815  calories. 

Instead  of  ham,  caviar  and  butter  with  sHces  of  toasted  roll,  or 
scrambled  eggs  with  smoked  meat,  may  be  given  in  the  forenoon. 
At  noon,  beefsteak,  fillet,  game,  or  fowl  are  allowed,  and  for  side 
dishes  some  mashed  carrots  or  spinach.  At  night,  calf's-foot  jelly 
and  omelette  soufBe. 

In  convalescence,  10  to  15  gm.  of  condensed  milk  or  malt  extract 
three  times  daily  after  meals  can  be  prescribed,  through  which  the 
nutritive  value  of  this  diet  is  considerably  increased. 


DIET    LISTS. 


229 


BILL  OF  FARE  FOR  ENLARGEMENT  OF  THE  STOMACH  WITH 
STENOTIC  AVPEARA-NCES.—itVege/e.) 


Albumin. 

Fat. 

Carbo- 
Hyukate. 

Alcohol. 

Morning: 

100  gm.  of  scraped  ham, 

Tea  with  50  gm.  of  cream,    .... 
Forenoon : 

25.0 
1.8 

12.0 

8.0 
13-3 

lO.O 

1-5 

0.5 

13-3 

1-5 

4-3 

1.2 

7.2 

'  18 

16.0 

21.3 

1.8 
22.0 

550 
9.6 

10  gm.  of  cognac, 

Noon  : 

100  gm.  of  scraped  beefsteak,    .    .    . 

100  gm.  of  mashed  potatoes,     .    .    . 
Afternoon : 

Tea  with  50  gm.  of  cream,     .... 
Evening  : 

100  gm.  of  roast  chicken  (hashed),  . 

100  gm.  of  flour  puff  paste,  .... 
During  the  Day  : 

80  gm.  of  toast, 

Night  : 

200  gm.  of  milk, 

20.7 
31 

1.8 

20.7 
4.2 

8.5 

6.4 

13-8 

Total              

104.2 

60.8 

127.5 

13-8 

Calories  about, 

427 

56S 

722 

100 

Total  combustion  value  about  1 8 14  calories. 


With  this  bill  of  fare  it  is  most  difficult  to  have  a  variety.  Beef- 
steak, scraped  fine  from  lean  meat,  chicken,  pigeon,  lean  ham, 
smoked  meat,  cold  roast  beef,  and  fillet  are  recommended. 

In  the  evening  one  may  often  serve  also  calf 's-foot  jelly,  tapioca, 
or  milk  jelly.  With  occasional  improvement  condensed  milk, 
cream,  malt  extract,  and  milk  jellies  may  be  tried  by  spoonfuls  be- 
tween meals.  Besides  these  a  nutritive  clyster  (following  a  cleansing 
enema)  is  to  be  given  twice  a  day  in  these  severe  cases. 

One  can  waive  the  somewhat  tedious  meat-pancreas  clysters, 
since  a  considerable  quantity  of  meat  is  taken  in  per  os,  and  one 
can  adopt  either  Ewald's  or  Boas'  method,  since  according  to  the 
investigations  of  Eichhorst  {Pfli'igers  Archiv,  Bd.  iv,  1871),  Ewald 
{Zeitschrift  f.  kliii.  Med.,  Bd.  xii,  1887),  and  Huber  {DeutscJi.  Archiv 
f.  klin.  Med.,  Bd.  XLVii),  the  digestion  of  the  albumen  of  eggs  and 
milk  proceeds  very  well  without  previous  peptonization  in  the 
rectum,  while  it  is  considerably  increased  by  the  addition  of  com- 


230 


DIETETIC    KITCHEN. 


mon  salt  (one  gm.  to  one  egg)  (see  chapter  on  rectal  alimentation). 
Boas  ("  Diagnostik  und  Therapie  der  Magenkrankheiten,"  zweite 
Aufl.,  1891,3.  244),  has  followed  out  rectal  nutrition  for  ten  to 
fourteen  days,  in  cases  of  severe  gastrectasia  with  symptoms  of 
fermentation,  and  attained  not  only  the  disappearance  of  the  symp- 
toms of  fermentation,  and  a  considerably  better  general  state  of 
health,  but  also  temporary  increase  in  weight, — a  success  which 
lasted  from  three  to  four  months. 

If  to  the  preceding  bill  of  fare  two  more  nutritive  clysters  are 
added,  the  patient  receives  : 


Albumin. 

Fat. 

Carbo- 
hydrate. 

Alcohol. 

4  eggs, 

100  gm.  of  red  wine, 

20 

24 

3-3 

7.8 

Total, 

20.0 

24.0 

3-3 

7.8 

Calories, 

82 

224 

31 

54 

Total  combustion  value  about  391  calories. 

If  we  assume  that  of  this  only  ten  gm.  of  albumen,  two  gm.  of 
carbohydrate,  ten  gm.  of  fat,  and  four  gm.  of  alcohol  should  attain 
resorption,  we  would  obtain  a  total  combustion  value  of  about  1750 
calories. 

With  two  nutritive  clysters,  according  to  Boas,  the  following 
increase  would  be  attained  : 


Albumin. 

Fat. 

Carbo- 
hydrate. 

Alcohol. 

1500  gm.  of  milk,     .    / ". 

17.0 
24.0 

'  8.8 

18.2 
20.0 

■  3.6 

24.2 
25.0 

4  eggs,     .....    

30  gm.  of  red  wine, 

40  gm.  of  leguminose  flour, 

2.0 

Total, 

49.8 

41.8 

49.2 

2.0 

If  half  be  assumed  as  resorbed,  then  there  would  be  an  addition 
of  about  25  gm.  of  albumin,  about  20  gm.  of  fat,  about  25  gm.  of 
carbohydrate,  about  one  gm.  of  alcohol.  This  would  give  a  total 
combustion  value  of  about  1850  calories  (Wegele). 


DIET    LISTS. 


231 


BILL  OF  FARE   FOR   GASTRIC   CARCINOMA   WITHOUT   PERCEPTIBLE 
STENOTIC  APPEARANCES.  — («^^§-^/^.) 


Albumin. 

Fat. 

Carbo- 
hydrate. 

Alcohol. 

Morning  : 

150  gm.  of  maltoleguminose  cocoa,    . 

Forenoon : 

200  gm.  of  kefir, 

Noon: 

150  gm.  of  maltoleguminose  soup,    . 
100  gm.  of  scraped  beefsteak,    .    .    . 

Afternoon : 

150  gm.  of  maltoleguminose  cocoa,    . 

Evening  : 

100  gm.  of  scraped  ham, 

150  gm.  of  tapioca, 

ID  o'clock  : 

200  gm.  of  kefir,      ........ 

With  the  cocoa,  30  gm.  of  honey,     . 

With  the  kefir,  20  gm.  of  cognac,     . 
During  the  Day  : 

6.0 

6.6 

4.0 
20.0 

6.0 

25.0 
7.0 

6.6 
0.4 

6.6 

4.0 

4-5 

0.15 
6.0 

4.0 

8.0 
5-0 

4-5 

I.O 

13-5 
3-8 
9-3 

13-5 

'  8.0 

3-8 
22.0 

350 

14.0 

Total, 

87.6 

37-1 

108.9 

15.0 

Calories  about, 

360 

350 

450 

100 

Total  combustion  value  about  1260  calories. 

For  a  change,  tea  can  be  often  given  instead  of  cocoa ;  where 
kefir  does  not  agree  with  the  patient,  or  is  refused  by  him,  one 
can  try  condensed  milk  with  cognac  instead  ;  further,  one  can  let 
him  eat  butter  upon  toast,  or  toasted  bread  with  the  tea,  and  also 
have  variety  in  the  meats,  as  long  as  the  appetite  for  them  remains. 

Naturally,  in  the  last  stages  a  considerable  narrowing  of  the  list, 
both  in  quantity  and  qualit}^  takes  place,  and  one  must  make  the 
greatest  concessions  to  the  individual  tastes  of  the  patient.  In  the 
morning  one  will  give  him  either  cocoa  or  tea,  with  slices  of 
toasted  roll  spread  with  meat  extract  or  caviar  ;  then  allow  a 
little  wine  with  one  soft  egg,  or  egg  with  cognac  and  sugar,  or  a 
glass  of  champagne;  at  noon  sweet-bread  in  soup,  smoked  ham, 
pickled  meat,  smoked  meat  (which  foods  are  more  difficult  of 
decomposition),  gruel,  rice,  mondamin  cooked  in  milk,  according 
to  taste.  In  the  afternoon,  tea  with  cognac  or  cocoa,  and  in  the 
evening  calf 's-foot  jelly,  or  meat-extract  jelly,  or  meal  soup  will 
be  suitable.  In  addition,  the  nutritive  clysters  mentioned  above. 
(A  more  detailed  calculation  of  the  diet  at  this  stage  has  little 
value,  and  is  therefore  omitted.) 


DIETETIC    KITCHEN. 


(I)    BILL  OF  FARE  FOR  CURE  OF  ULCER  (TO  BE  KEPT  UP  AT  LEAST 
TEN  DAYS).— [Leiide-F^nsoM- Wegele.) 


Morning: 

250  gm.  of  milk,       8.50 


Two  cakes  {5  gm.  each^, 

10  o'clock  : 

250  gm.  of  milk  or  bouillon, 

One  cake, 

12   O'CLOCK: 

150  gm.  of  bouillon, 

50  gra.  of  meat  solution  (or  one  egg), 

4   o'clock  : 

250  gm.  of  milk, 

Two  cakes, 

150  gm.  of  bouillon, 

50  gm.  of  meat  solution  (or  one  egg). 
Two  cakes, 


Total,     .    .    .    , 
Calories  about. 


Albumin. 

Fat. 

C.\KBO- 
HY  URATE. 

8.50 

9.00 

12.0 

I. ID 

0.50 

7-3 

8.50 

9.00 

12.0 

0.60 

0.25 

3-7 

0.75 

0.45 

0.9 

8.50 

3.00 

3-5 

8.50 

9.00 

12.0 

1. 10 

0.50 

7-3 

0.75 

0.45 

0.9 

8.50 

3.00 

3-5 

1. 10 

0.50 

7-3 

47-9 

3565 

70.4 

Total  combustion  value  about  860  calories. 


(2)  BILL  OF  FARE  FOR  CURE  OF  ULCER  (TO  BE  KEPT  UP  AT  LEAST 
SEVEN  'DKY?>).—{Leube-  Wegele.) 


Albumin. 


Morning: 

250  gm.  of  milk, 

Three  cakes, 

ID  o'clock  : 

200  gm.  of  bouillon, 

One  egg, 

Noon  : 

One  boiled  pigeon, 

About  200  gm.  of  rice  in  bouillon,  .... 
4  o'clock  : 

250  gra.  of  milk, 

Two  cakes, 

8  o'clock  : 

150  gm.  of  bouillon, 

100  gm.  of  sweet-bread, 

Total, 

Calories  about,      1       370 

Total  combustion  value  about  II 10  calories 


Fat. 


Carbo- 
hydrate. 


8.5 

9.00 

12.0 

1.8 

0-75 

II. I 

3-2 

4.40 

3-2 

6.0 

5.00 

•  •  • 

22.0 

I.OO 

0.7 

5.0 

2.00 

40.0 

8.5 

9.00 

12.0 

I.I 

0.50 

7-3 

6.4 

6.70 

9.0 

28.0 

0.40 

90.5 

38.75 

95-3 

390 


DIET    LISTS. 


233 


BILL  OF  FARE  FOR  CURE  OF  ULCER  (FOR   AT    LEAST  FIVE 

I)AYS).—{lVege/e.) 


Morning  : 

Two  cups  of  tea  or  coffee,  with  loo  gm.  of  milk, 

20  gm.  of  sugar, 

Three  cakes, 

10  o'clock  : 

200  gm.  of  bouillon, 

One  egg, . 

Noon  : 

200  gm.  of  soup,      

150  gm.  of  beefsteak, 

100  gm.  of  mashed  potatoes, 

4  o'clock  : 

Two  cups  of  tea  with  loo  gm.  of  milk,     .    .    .    . 

20  gm.  of  sugar, 

Three  cake?, 

EvEXl.\G : 

100  gm.  of  scraped  ham, 

200  gm.  of  soup,       

Total, 

Calories  about,      


Albumin. 


3-4 
0.5 
1.8 


3-2 
6.0 


3-2 
31.0 

3-1 


3-4 

1.8 

25.0 
3-2 


350 


Fat. 


3.60 
0.75 

4.40 
5.00 

6.00 
2.20 
0.85 

3.60 

0-75 

8.10 
6.00 


41-25 


380 


Carbo- 
hydrate. 


4-8 
18.2 
II. I 

3-2 

17.0 
21.3 

4-8 
18.2 
II. I 

17.0 


126.7 


520 


Total  combustion  value  about  1250  calories. 


(4)  BILL  OF  FARE  FOR  CURE  OF  ULCER  (TO  BE  KEPT  UP  AT  LEAST 

ONE  WEEK). 


Albumin. 


Carbo- 
hydrate. 


Morning  : 

Two  cups  of  tea  or  coffee,  with  100  gm.  of  milk, 

20  gm.  of  sugar,   ...  

One  sweetbread  (50  gm.), 

10  O'CLOCK  : 

200  gm.  of  bouillon, 

One  egg, 

NoON  : 

200  gm.  of  soup,      ■ 

150  gm.  of  roast  fowl, 

100  gm.  of  carrots  or  spinach, 

200  gm.  of  light  flour  food, 

4  O'CLOCK: 

Two  cups  of  tea  or  coffee,  with  100  gm.  of  milk, 

20  gm.  of  sugar, 

One  sweetbread, 

16 


3-4 
0-5 
4-5 


3-2 
6.0 


3-2 

27.6 

I.O 

9.0 

3-4 
0.5 
4-5 


3-6 

0-5 

4-4 
5.0 

6.0 

14.0 

0.2 

8.4 

3-6 
0.5 


4-8 
18.2 
29.0 

T,.2 


17.0 

1-7 

8.1 
45-0 

4.8 
18.2 
29.0 


234 


DIETETIC    KITCHEN, 


(4)  Bill  of  Fare  for  Cure  of  Ulcer  (to  be  kept  up  at  least  one  week) 

[Continued'). 


Albumin. 


Carbo- 
hydrates. 


Evening : 

100  gm.  of  cold  roast  meat, 
250  gm.  of  tapioca,      .    . 

10  o'clock  at  night  : 

250  gm.  of  milk,  .... 

Total, 

Calories  about,      .    . 


38.2 
7.0 

8.5 


2.8 
9.0 


8.0 


120.5 


63.0 


199.0 


495 


585 


815 


Total  combustion  value  about  1900  calories. 

Instead  of  tea  or  coffee,  milk  may  also  be  served,  by  which 
the  nutritive  value  of  this  diet  is  not  inconsiderably  increased. 
Concerning  the  first  list  it  is  to  be  remarked  that  instead  of  meat 
solution  eggs  may  also  be  given  (stirred  into  the  soup). 

Further,  in  the  second  and  third  lists  it  is  allowable  to  give 
two  or  three  soft  eggs  instead  of  meat  in  the  evening. 

The  fourth  list  may,  after  a  time,  be  quantitatively  and  qualita- 
tively expanded,  since  the  following  are  allowed  :  Meats  (fillet,  roast 
beef,  beefsteak,  roast  veal  "  from  the  leg,"  spring  chicken,  pigeons, 
partridges,  venison). 

Fish,  pike,  and  perch  (boiled)  are  allowable. 

Vegetables, — mashed  potatoes,  spinach,  and  golden  turnips. 

Of  the  farinaceous  foods,  the  light  puff  paste  of  rice,  fine  oat 
meal,  tapioca,  and  omelette  souffle  come  under  consideration. 

At  evening,  mushes  with  whisked  eggs  ;  preserved  or  stewed 
fruit ;  stewed  apples  may  be  tried  gradually. 

Salads  are  entirely  to  be  avoided.  Wines  can  now  be  permitted 
in  small  quantities  before  meals.  By  gradual  increase  in  quantity, 
one  must  attempt  to  give  the  body  the  necessary  increase  in  material. 


BILL  OF  FARE   FOR  CHRONIC   DIARRHEA  (Severe 

Cases). — 

{Wegele.) 

Albumin. 

Fat. 

Carbo- 
hydrate. 

Alcohol. 

Morning  : 

200  gm.  of  acorn  cocoa,  boiled  in  water, 
One  soft  egg, 

2-3 

6.0 

3.60 
5.00 

12.0 

DIET    IN    CHRONIC    DIARRHEA.  235 

Bill  of  Fare  for  Chronic   Diarrhea  (Severe  Cases). — [JVegele)  {Continued). 


Forenoon : 

250  gm.  of  decoction  of  whortleberries. 
(from  80  gm.  of  dried  berries) ,     .    . 
250  gm.  of  slimy  soup,      .... 

One  egg  in  the  soup, 

100  gm.  of  scraped  meat  (lean),      .    . 
50  gm.  of  rice  in  bouillon,      .    .    .    . 
Afternoon : 

250  gm.  of  whortleberry  decoction,     . 

Evening  : 

250  gm.  of  maltoleguminose  soup,  .    . 

With  one  egg, 

150  gm.  of  minced  chicken,     .    ,    .    . 

During  the  Day  : 

75  gm.  of  toast, 

200  gm.  of  whortlebern,'  wine,     .    .    . 

ID  o'clock  at  night  : 

250  gm.  of  barley  mush  (20  ;   250),     . 


Total, 


Calories  about. 


Albumin. 


0.6 


9.0 


Fat. 


C.-VRBO- 
HYDRATE. 


Alcohol. 


87.2 


^60 


1.30 

4-7 

4.00 

/O 

5.00 

1.50 

0.50 

38.0 

1.30 

4-7 

0.25 

15-5 

5.00 

9.00 

12.0 

1.50 

42.5 

7.0 

4.00 


42.00 


168.9 


390 


17.0 


Total  combustion  value  about  1440  calories. 

At  the  beginning  of  convalescence  light  flour  foods  are  allowed 
at  noon  ;  afternoon,  instead  of  the  whortleberry  decoction,  acorn 
cocoa  may  be  substituted  ;  at  noon,  roast  fowl,  beefsteak,  fillet,  roast 
beef,  and  gradually  pass  over  to  the  following  list : 


DIET  LIST  FOR  CHRONIC  DIARRHEA  (Less  Severe  Cases)  [IVegele). 


Albumin. 

Fat. 

C.\KBO- 
HYURATE. 

Alcohol. 

Morning  : 

200  gm.  of  acorn  cocoa,         .... 

2.30 

6.00 

8.20 

5-50 

6.00 

28.00 

6.00 

2.30 

3-6 
5-0 

5-7 
4.0 

lO.O 

1-7 
3-6 

12.00 

2.00 

7-50 

1.80 
42.70 

12.00 

Forenoon : 

250  gm.  of  kefyr  (four  days  old),  .    . 

Noon  : 

250  gm.  of  soup, 

3-2 

150  gm.  of  roast  chicken,  .... 
200  gm.  of  mashed  potatoes,      .    .    . 

4  O'CLOCK: 

250  gm.  of  acorn  cocoa,     ... 

236  DIETETIC    KITCHEN. 

Diet  List  for  Chronic  Diarrhea  (Less  Severe  Cases). — {IVegcIe)  {Condimed). 


Albumin. 

F--           ^.17^..      A.-cc,Hou 

6  o'clock  : 

250  gm.  of  kefyr, 

8  o'clock  : 

200  gm.  of  soup, 

8.20 

3-30 

6.00 

28.  GO 

8.20 

9.00 
0.15 

5.7          2.00           3.2 

6.0          17.00           .    .    . 

50        

0.5        .  .          •  ■  •   , 

5.7         2.00          3.2 
1.5        42.50        .  .  . 

16.6            0.12 

100  gm.  of  sweetbread, 

10  o'clock  : 

250  gm.  of  kefyr, 

During  the  Day  : 

75  gm.  of  toast,  or  toasted  bread,    . 

250  gm.  of  whortleberry  wine,      .    . 

.  .          8.75        21.5 

Total, 

127.00 

79.6      150.25        31.3 

Calories  about, 

520 

740             615              210 

Total  combustion  value  about  2080  calories. 

After  convalescence  has  begun,  ha\-e  the  acorn  cocoa  prepared 
with  milk  ;  add  at  noon  light  foods  ;  at  night  give  milk  mush  for 
a  change ;  gradually  increase  the  amount  of  kefyr  given  and  thus 
gradually  a  diet  of  about  2500  calories  combustion  value  is  reached, 
which  is  to  be  considered  sufficient. 

DIET  LIST  FOR  CHRONIC  CONSTIPATION.— ( rr^^^/^-.) 


Morning: 

Before    breakfast,    Bedford    Magnesia 

Spring  Water,  ^4  liter. 

200  gm.   of  milk  and  coffee,      .    .    . 

30  gm.   of  butter, 

30  gm.   of  honey, 

100  gm.   of  Graham  bread,    .    .    . 

300  gm.   of  buttermilk, 

Noon  : 

200  gm.  of  bouillon, 

200  gm.  of  mutton, 

300  gm.  of  crisped  cabbage,  .... 

200  gm.  of  plums, 

300  gm.  of  white  wine  or  apple  cider, 
Afternoon  : 

300  gm.   of  buttermilk, 


12.15 

1. 00 

23.20 

4.20 

0.80 


Fat. 


2.80 


0.60 
50-50 
14.40 


2.80 


Carbo- 

HYDR.\TE. 


3.20 

4.40 

3.20 

0.21 

24-50 

0-15 

0-35 

0.03 

17. CO 

1.20 

0.70 

21.60 

11.60 

9.00 

11.20 


Alcohol. 


24.7 


DIET    FOR    CHRONIC    CONSTIPATION. 

Diet  List  for  Chronic  Constipation. — {Wegele)  {Contimied^. 


237 


Albumin. 

Fat. 

HV.'r;s.    '    AX-COKOX.. 

Evening  : 

150  gm.  of  meat, 

30  gm.  of  butter, 

300  gm.  of  stewed  apples,      .... 
For  the  several  meals,  250  gm.  of  Graham 

bread,    

After  evening  meal,  750  gm.  of  beer,  .    . 

28.20 
0.21 
1. 00 

22.50 
42.60 

11.00 

24.50 

2.50 
6.50 

0.  10                 ... 

0.15                 ... 

39.00                 .      .      . 

12500                 .      .      . 
4.70                  28.8 

Total, 

145-77 

194-50 

245-80     ;      53-5 

Calories  about,          

600 

1800 

1000      i      375 

Total  combustion  value  about  ^800  calories. 


This  list  is  easily  varied  in  accordance  with  above  statements, 
and  eventually  it  may  be  diminished  along  the  entire  scale,  or  it 
may  be  changed  with  regard  to  co-existent  stomach  troubles.  For 
the  rest  it  is  to  be  noted  that  with  the  difficult  solubility  of  many 
of  the  foods  mentioned,  and  with  an  acceleration  of  digestion 
brought  about  by  the  diet  prescribed,  a  considerable  part  of  the 
nutriment  introduced  WMth  the  "  ingesta  "  will  be  only  partially 
turned  to  the  best  advantage.  Naturally,  if  the  chronic  constipation 
is  due  to  real  catarrh,  one  must  prescribe  less  irritating  food  and 
give  the  softer  vegetables,  such  as  cauliflower,  spinach,  asparagus, 
carrots  ;  also  the  legumes  and  preserves  more  in  form  of  purees. 

DIET  LIST  FOR  YiXY^'^KQXUVTY.—^Boas-Wegde-Fleischer.) 


Morning  : 

100  gm.  of  tea  with  milk,      .    .        .    . 

2  soft  eggs, 

100  gm.  of  raw  ham, 

50  gm.  of  cream, 

NoON: 

200  gm.    of  aleuronat  meal  soup  (10 
al.  ;   20  oatmeal  ;   250  soup),      .    . 

150  gm.  of  beefsteak, 

200  gm.  of  mashed  potatoes,    .... 
100  gm.    of  white   wine,  mixed  with 
Saratoga  Vichy  or  Biliner  water,  . 
Afternoon : 

100  gm.  of  tea, 

150  gr.  of  cream, 


Fat. 


3-4 
12.0 
25.0 

2.0 


10.2 

58.0 

6.2 


3-4 
2.0 


3-6 

lO.O 

8.0 
13-5 


1.7 
3-0 
1-7 


3-6 
13-5 


Carbo- 
hydrate. 


Alcohol. 


4.8 
1-7 

8.0 

42.6 

3-5 

4.8 
1-7 


8.0 


238  DIETETIC    KITCHEN. 

Diet  List  for  Hyperacidity. — [^Boas-Wegek- Fleischer)  {Ccmtinued). 


Fat. 


Carbo- 
hydrates 


Evening  : 

50  gra.  of  cold  roast  meat, 

2  scrambled  eggs, 

,     100  gm.  of  wine, 

For  the  several  meals,  lOO  gm.  of  aleuronat 

toast, 

10  o'clock  at  night: 

250  gm.  of  milk, 


60.2 
12.0 


Total, 


Calories   about, 


28.3 
8.5 


4.0 
12.0 


1-5 
9.0 


229.2 


85.1 


940 


790 


3-5 
66.7 
12.0 


8.0 


149.4 


16.0 


600 


Total  combustion  value  about  2500  calories. 

With  the  tea  a  little  sugar  is  to  be  allowed,  and  the  white  wine 
is  usually  to  be  mixed  with  an  alkaline  acidulous  water  not  con- 
taining too  much  carbonic  acid  (such  as  Biliner  water).  When 
convalescence  sets  in,  the  daily  amount  of  milk  is  to  be  increased. 


DIET  LIST  FOR  HYPERSECRETION.— ( ?Fd>-^^.) 

Albumin. 

Fat.    • 

Carbo- 
hydrate. 

Morning  : 

Tea  with  100  gm.  of  milk, 

3-4 

3-0 

4.8 

2  soft  eggs, 

12.0 

lO.O 

Forenoon : 

150  gm.  of  calf  s-foot  jelly,          

35-0 

17.0 

I.O 

Noon: 

150  gm.  of  sweetbread  in  bouillon, 

32.0 

250  gm.  of  tapioca  mush, 

12.0 

8.0 

II.O 

50  gm.  of  cream, 

2.0 

13-5 

1-7 

Afternoon : 

200  gm.  of  milk, '.    .    .    . 

6.8 

6.0 

9.6 

Evening: 

200  gm   of  ham, 

48.0 

70.0 

2  scrambled  eggs, 

12.0 

12.0 

For    the     several     meals,     loo     gm.    of     aleuronat 

toast, 

28.3 

1-5 

66.7 

ID  p.  M.  : 

100  gm.  of  milk 

6.5 

6.0 

lO.O 

During  Night  : 

100  gm.  of  milk, 

6.5 

6.0 

10. 0 

Total, 

218.0 

147.0 

104.8 

Calories  about,      

900 

1360 

430 

Total  combustion  value  about  2700  calories. 


MENU    FOR    HYPERACIDITY. 


239 


Of  course,  other  meats  than  those  mentioned  above  may  be 
chosen,  only  the  glutinous  are  particularly  to  be  selected;  event- 
ually also  scraped  meat,  ham,  etc. 

With  convalescence  go  over  to  the  preceding  list.  With  nightly 
complaints  in  consequence  of  acid  formation,  there  is  to  be  re- 
commended, besides  milk  or  glair  water,  especially  raw  or  hard 
grated  eggs  and  drinking  afterward  of  alkaline  waters.  Pen- 
zoldt  recommends  the  addition  of  one-fourth  to  one-third  lime- 
water  to  the  milk. 

As  concerns  the  power  of  the  various  foods  to  combine  with 
HCl.the  following  table  is  based  upon  results  obtained  experiment- 
ally by  Fleischer  ("  Krankh.  d.  Speiserohre,  d.  Mag.  u.  d.  Darms," 
Wiesbaden,  1896,  p.  932): 


Meats,  100  gm.,  Combine  With  : 

Calf's  brain,  boiled, 

Liver  pudding, 

Sweetbread,  boiled, 

Mettwurst, 

Saveloy,  

Black  pudding, 

Pork,  boiled, 

Ham,  boiled, 

Ham,  raw, 

Mutton,  boiled, 

Beef,  boiled 

Veal,  boiled, 

Leube-Rosenthal's  meat  solution, 

Other   Foods. 

Beer, 

Milk,     .    .        

Wheatbread, 

Graham  bread, 

Black  (gray)  bread,     

Pumpernickel, 

Hand  cheese, 

Fromage  de  Brie, 

Edam  cheese, 

Brick  cheese, 

Pease  sausage, 

Roquefort  cheese, 

Swiss  cheese, 

Cocoa, 


Pure  HCl. 


0.65 
0.80 
0.90 
1. 00 
I  10 
1.30 
1.60 
1.80 
1.90 
1.90 
2.00 
2.20 
2.20 


O.IO 

0.36 
0.30 
0.30 
0.50 

0.70 
1. 00 

1.30 

1.40 
1.70 
1.70 
2.10 
2.60 
4.10 


25  Per  Cent. 
HCl. 


2.6 
3-2 
3-6 

4.0 

4-4 
5-2 
6.4 
7.2 
7.6 
7.6 
8.0 


.40 
1.44 
1.20 
1.20 
2.00 
2.80 
4.00 
5.20 
5.60 
6.80 
6.80 
8.40 
10.40 
16.40 


i2i^   Per 
Cent.  HCl. 


55-2 

6.4 

7.2 

8.0 

8.8 

10.4 

12.8 

14.4 

15-2 

15-2 
16.0 
17.6 
17.6 


2.40 

2.40 

4.00 

5.60 

8.00 

10.40 

1 1. 20 

13.60 

13.60 

16.80 

20.80 

32.80 


The  author's  personal  views  on  the  dietetic  treatment  of  hyper- 
acidity and  hypersecretion  have  been  clearly  stated  in  pages  188  and 


240  DIETETIC    KITCHEN. 

189,  on  the  basis  of  a  very  large  number  of  quantitative  analyses 
of  the  gastric  contents  of  42  normal  healthy  adults,  he  has  become 
convinced  that  proteids,  such  as  beef,  eggs,  fish,  etc.,  cause  a 
stronger  secretion  of  HCl  than  amylaceous  foods,  such  as  rice, 
sago,  farina,  cerealin.  When  the  glandular  layer  is  in  a  state  of 
increased  excitation  it  is  logical  to  avoid  proteid  and  albuminous 
food  as  much  as  possible.  We  have  made  numerous  prolonged 
observations  showing  that  amylaceous  foods  and  fats  can  maintain 
the  nitrogen  equilibrium,  and  even  add  to  body  weight  when 
proteids  are  excluded.  We  do  not  wish  to  defend  the  standpoint 
of  the  vegetarian,  as  we  generally  allow  a  small  quantity  of 
easily  digestible  meat  for  dinner,  and  advise  about  i  ^^  liters  of 
milk  if  it  agrees  well.  The  views  of  v.  Sohlern  on  this  question 
merit  careful  investigation. 

SCHEDULE  FOR  INTESTINAL  ANTISEPSIS  BY  MILK  DIET. 
Also  Available  in  Neurasthenia,  Sensory  and   Secretory  Neuroses. — 

{Bzirkart.') 
First  Day  : 
7.30  a.  m. — One-half  of  a  liter  of  milk  and  two  pieces  of  toast  (the  milk  is  to  be 

taken  a  mouthful  or  a  spoonful  at  a  time,  ^  of  a  liter  in  one-half  hour). 
10  A.  M. — One-third  of  a  liter  of  milk  and  one  toast. 
12.30  p.  M. — One  plate  of  soup  with  one  egg,  50  gm.  of  roast  meat.      Potato 

puree. 
3.30  p.  M. — One-third  of  a  liter  of  milk  and  one  toast. 
5.30  p.  M. — One-half  of  a  liter  of  milk  and  two  toasts. 
8  p.  M. — One-half  of  a  liter  of  milk,  50  gm.  of  roast  meat,  wheat  bread  and 

butter. 
On  the  ninth  day  the  following  list  is  reached  : 
7.30  a.  m. — One-half  of  a  liter  of  milk  and  two  toasts. 
8.30  a.  m. — Coffee  and  cream,  wheat  bread  and  butter. 
10  A   M. — One-third  of  a  liter  of  milk  and  two  toasts. 
12  M. — One-half  of  a  liter  of  milk. 
I  p.  M. — Soup  with  one  t%g,  100  gm.  of  meat,  mashed  potatoes,  75  gm.  of 

stewed  prunes. 
3.30  p.  M. — One-half  of  a  liter  of  milk. 
5.30  p.  M. — One-third  of  a  liter  of  milk  and  two  toasts. 
8  p.  M. — One-half    of   a   liter   of  milk,   60   gm.    of  meat,    wheat   bread    and 

butter. 
9.30  p.  M. — One-third  of  a  liter  of  milk  and  two  toasts. 


FATTENING    CURE    FOR    NEUROSES, 


241 


On  the  fifteenth  day  Burkart  (in  a  severe  case  of  dyspepsia  on 
hysterical  basis)  reached  the  following  most  respectable  diet  list : 


7  A.  M. 

500  gm.  of  milk, 

8  A.  M. 

One  small  cup  of  coffee  or  tea,  with  20  gm.  of 

cream, 

80  gm.  of  cold  meat, 

One  French  roll, 

20  gm.  of  butter, 

100  gm.  of  roast  potatoes, 

10  A.  M. 

300  gm.  of  milk, 

12  M. 

300  gm.  of  milk, 

I  P.  M. 

200  gm.  of  soup, 

200  gm.  of  roast  meat, .... 

200  gm.  of  mashed  potatoes,      .    i 

125  gm.  of  prunes, 

200  gm.  of  flour  food, 

3.30  p.  M. 

500  gm.  of  milk, 

5.30  P.M. 

300  gm.  of  milk, 

80  gm.  of  cold  meat, 

One  French  roll,       

20  gm.  of  butter, 

8  P.  M. 

80  gm.  of  roast  meat, 

40  gm.  of  toast, 

5,00  gm.  of  milk, 

9.30  p.  M. 

500  gm.  of  milk, 

20  gra.  of  toast,       


17.0 


Total, !     295.0 

Calories  about,       


Fat. 


Carbo- 
hydrate. 


24.0 


0.7 

30.8 

50 

2.0 

0.7 

4-5 
0.3 

0.5 
16.6 

29.0 

O.I 

1.8 

1 0.0 

25.0 

10.2 

10.9 

14.4 

10.2 

10.9 

14.4 

2.2 

76.4 

6.2 

0.4 

12.8 

30 
5-4 
1-7 

21.2 

II. 4 

42.6 

8.3 
45-0 

.7.0 

18.2 

24.0 

10.2 
308 

10.9 
2.0 

14.4 

4-5 

05 
16.6 

29.0 
0.1 

30.8 

2.0 

0.6 
17.0 

5-2 
18.2 

33-2 
24.0 

17.0 
0.3 

18.2 

2.6 

24.0 
16.6 

295.0 

199.8 

380.2 

1550 


Total  combustion  value  about  4600  calories. 


Effects  of  Cooking  on  Food. — The  practice  of  cooking  is  not 
equally  necessary  in  regard  to  all  articles  of  food.  There  are  im- 
portant differences  in  this  respect,  and  it  is  interesting  to  note  how 
correctly  the  experience  of  mankind  has  guided  them  in  this 
matter.  The  articles  of  food  which  we  still  use  in  the  uncooked 
state  are  comparatively  few  ;  and  it  is  not  difficult  in  each  case  to 


242  EFFECTS  OF  COOKING  OX  FOOD. 

indicate  the  reason  of  the  exemption.  Fruits  which  we  consume 
largely  in  the  raw  state,  owe  their  dietetic  value  chiefly  to  the 
sugar  which  they  contain ;  but  sugar  is  not  altered  by  cooking. 
Salads  may  be  regarded  more  as  a  relish  for  other  food,  and  as 
having  a  quasi-medicinal  purpose,  rather  than  as  a  substantial 
source  of  nutriment.  Milk  is  consumed  by  us,  both  cooked  and 
uncooked,  indifferently,  and  experience  justifies  this  indifference; 
for  Sir  William  Roberts  found  on  trial  that  the  digestion  of  milk 
by  pancreatic  extract  was  not  appreciably  hastened  by  previously 
boiling  the  milk. 

This  eminent  writer  characterizes  our  practice  in  regard  to  the 
oyster  as  being  exceptional  and  furnishing  a  striking  example  of 
the  general  correctness  of  the  popular  judgment  on  dietetic 
questions.  The  oyster  is  almost  the  only  animal  substance  which 
we  habitually,  and  by  preference,  eat  in  the  raw  or  uncooked  state  ; 
and  it  is  interesting  to  know  that  there  is  a  sound  physiological 
reason  at  the  bottom  of  this  preference.  The  fawn-colored  mass 
which  constitutes  the  dainty  of  the  oyster  is  its  liver,  and  this  is 
little  else  than  a  heap  of  glycogen,  or  animal  starch.  Associated 
with  the  glycogen,  but  withheld  from  actual  contact  with  it  during 
life,  is  its  appropriate  digestive  ferment — the  hepatic  diastase.  The 
mere  crushing  of  the  dainty  between  the  teeth  brings  these  two 
bodies  together,  and  the  glycogen  is  at  once  digested,  without  other 
help,  by  its  own  diastase.  The  oyster  in  the  uncooked  state,  or 
merely  warmed,  is,  in  fact,  self-digestive.  But  the  advantage  of 
this  provision  is  wholly  lost  by  cooking,  for  the  heat  employed 
immediately  destroys  the  associated  ferment,  and  a  cooked  oyster 
has  to  be  digested,  like  anv  other  food,  bv  the  eater's  own  digestive 
powers. 

With  regard,  however,  to  the  staple  articles  of  our  food,  the 
practice  of  cooking  them  beforehand  is  universal.  In  the  case  of 
the  farinaceous  articles  cooking  is  actually  indispensable.  When 
men  under  the  stress  of  circumstances  have  been  compelled  to  sub- 
sist on  the  uncooked  grain  of  the  cereals,  they  have  soon  fallen  into 
a  state  of  inanition  and  disease.  By  the  process  of  cooking,  the 
starch  of  the  grain  is  not  only  liberated  from  its  protecting  envel- 
opes, but  it  undergoes  a  chemical  change  by  which  it  is  trans- 
formed into  the  gelatinous  condition,  and  this  immensely  facilitates 
the  attack  of  the  diastatic  ferments.  A  change  of  equal  import- 
ance seems  to  be  induced  in  the  proteid  matter  of  the  grain.     Sir 


THE  PALATE  A  SKILFUL  GUIDE.  243 

William  Roberts  found  that  the  gluten  of  wheat  was  much  more 
digestible  by  both  artificial  gastric  juice  and  by  pancreatic  extract 
in  the  cooked  than  in  the  uncooked  state.  In  regard  to  meat 
the  advantage  of  cooking  consists  chiefly  in  its  effects  on  the  con- 
nective tissue  and  the  tendinous  and  aponeurotic  structures  asso- 
ciated with  muscular  fiber.  These  are  not  merely  softened  and 
disintegrated  by  cooking,  but  are  chemically  converted  into  the 
soluble  and  easily  digested  form  of  gelatin.  Sir  William  Roberts 
made  instructive  observations  on  the  effects  of  cooking  on  the 
contents  of  the  egg.  The  change  induced  on  egg-albumen  by 
cooking  is  very  striking.  For  the  purpose  of  testing  this  point, 
he  employed  a  solution  of  egg-albumen  made  by  mixing  white-of- 
egg  with  nine  times  its  volume  of  water.  This  solution  when 
heated  in  the  water-bath  does  not  coagulate  nor  sensibh-  change  its 
appearance,  but  its  behavior  with  the  digestive  ferments  is  com- 
pletely altered.  In  the  raw  state  this  solution  is  attacked  very 
slowly  by  pepsin  and  acid,  and  pancreatic  extract  has  almost  no 
effect  on  it ;  but  after  being  cooked  in  the  water-bath,  the  albumen 
is  rapidly  and  entirely  digested  by  artificial  gastric  juice,  and  a 
moiety  of  it  is  rapidly  digested  by  pancreatic  extract.* 

Indications  of  the  Palate. — "  The  indications  of  the  palate  are  of 
great  importance  in  the  regulation  of  diet,  and  should  always  be 
inquired  into  and  carefully  considered.  The  palate  is  placed  Hke 
a  dietetic  conscience  at  the  entrance  gate  of  food,  and  its  appointed 
function  is  to  pass  summary  judgment  on  the  wholesomeness  or 
unwholesomeness  of  the  articles  presented  to  it.  It  acts  under  the 
influence  of  a  natural  instinct,  which  is  rarely  at  fault.  This  in- 
stinct represents  an  immense  accumulation  of  experience,  partly 
acquired  and  partly  inherited.  It  is,  of  course,  not  infallible — no 
instinct  is  ;  but  so  close  and  true  are  the  sympathies  of  the  palate 
with  the  stomach  and  the  rest  of  the  organism,  that  its  dictates  are 
entitled  to  the  utmost  deference  as  those  of  the  rightful  authority 
in  the  choice  of  food.  I  am,  of  course,  aware  that  the  palate — or, 
rather,  the  civilized  palate — is  not  always  credited  with  these  solid, 
good  qualities.  Some  persons  there  are.  not  medical  authorities, 
who  distrust  its  office,  and  regard  its  indications  with  suspicion,  as 
if  they  were  the  suggestions  of  some  frivolous  and  wanton  agency, 
tempting  men  to  a  vain  gratification  of  the  senses,  rather  than  as 

*The  fact  was  probably  overlooked  that  raw  egg-albumen  does  not  require  digestion 
and  can  be  absorbed  from  the  intestine  as  such. 


244  DIETETICAL    COOKING. 

those  of  an  honest  and  skilful  guide  in  the  choice  of  food.  This 
puritanical  view  of  the  palate  is  wholly  unscientific  ;  it  moreover 
implies,  to  speak  figuratively,  a  gross  slander  on  a  responsible  and 
rarely  endowed  organ,  which  has  performed  in  the  past,  and  still 
performs,  most  difficult  and  most  complicated  functions  with  con- 
spicuous success  ;  for  who  shall  venture  to  say,  that  in  the  evolu- 
tion of  the  human  animal  from  the  short-lived,  immoral,  and  stupid 
savage,  with  his  diet  of  wild  fruit,  roots,  raw  flesh,  and  unfiltered 
water,  to  the  status  of  civilized  man  the  promptings  of  the  palate 
have  not  played  an  important  and  even  indispensable  part  ?  We 
are  apt  to  forget  that  there  is  no  such  a  thing  as  an  absolutely  good 
or  an  absolutely  bad  flavor  to  the  animal  palate.  Sweet  things  are 
indifferent  to  the  palate  of  the  carnivora  ;  and.  conversely,  the  taste 
of  flesh  has  no  attraction  to  the  herbivora.  Each  animal  has  its 
own  gustatory  standard,  which  is  accurately  adjusted  to  the  wants 
of  its  particular  economy."  (Sir  William  Roberts,  "  Digestion  and 
Diet.") 

DIETETICAL  COOKING.* 

General  Remarks. — It  is  evident  that  the  subtle  art  of  cooking 
can  be  practised  with  advantage  to  those  suffering  from  indigestion 
only  by  those  who  understand  thoroughly  the  general  fundamental 
principles  of  the  art,  and  have  in  addition  some  experience  therein. 
But  if  diligence,  care,  and  cleanliness  are  very  desirable  qualities 
in  cooking  for  people  in  good  health,  they  become  an  absolute 
necessity  for  those  who  undertake  the  preparation  of  food  for  diges- 
tive organs  which  are  not  in  good  health.  By  no  means  should 
the  attention  be  taken  from  the  work  by  other  matters,  for  in  that 
case  the  care  which  is  necessary  will  suffer,  and  the  most  scrupulous 
cleanliness  must  be  applied  (Wegele). 

It  should  be  understood  here  that  we  have  confined  ourselves  to 
the  most  necessary  things,  and  have  not  considered  the  details  con- 
cerning the  arrangement  of  the  kitchen,  construction  of  the  fire- 
place, the  cooking  utensils  and  fuel,  food-stuffs  or  their  adultera- 
tion;    and,  further,   we   have   not    undertaken    the    description    of 

*  We  have  availed  ourselves  of  a  large  number  of  works  in  compiling  this  particular 
chapter.  The  name  of  the  originator  of  any  particular  article  of  diet  has  been  added  to 
the  directions  given  whenever  it  was  obtainable.  Of  the  larger  works  used  we  mention 
Sir  Wm.  Roberts,  Munk  and  Uffelmann,  Wegele,  Biedert  and  Langermann,  Oilman 
Thompson,  Boas,  Penzoldt  and  Stintzing's  "  Handbuch  d.  Therapie,"  etc. 


GENERAL    DIRECTIONS    REGARDING    COOKING.  245 

complicated  dishes,  but  have  given  directions  for  the  prepara- 
tion of  only  the  simplest  every-day  dishes  in  such  a  way  as  to 
serve  dietetical  purposes.  In  this  respect  the  advice  of  Pen- 
zoldt  deserves  consideration,  to  use  vessels  with  protecting  lids 
for  the  keeping  of  foods  which  are  to  be  eaten  later  when  cold. 
Naturally  all  food-stuffs  must  be  of  the  best  quality,  for  the  best  is 
just  good  enough  for  the  sick.  Aside  from  this,  nothing  in  the 
slightest  degree  spoiled  may  be  used  in  cooking  for  the  sick.  In 
the  eulogy  of  the  palate  we  have  already  emphasized  appetizing 
preparation,  for,  as  is  well  known,  dyspeptics  are  easily  seized  by 
nausea,  while  on  the  other  hand  a  suitable  way  of  preparing  food 
may  stimulate  the  appetite.  For  the  same  reason,  every  after-taste 
due  to  the  character  of  the  cooking  utensils  or  their  uncleanliness 
is  to  be  avoided  as  far  as  possible,  and  the  utensils  should  be, 
wherever  possible,  earthen,  enameled,  or  nickel-plated.  Food 
must  never  be  brought  to  the  table  too  hot,  for  the  patients  are  thus 
tempted  to  eat  them  in  this  state  in  spite  of  the  directions  of  the 
physician,  and  on  this  account  it  is  best  to  put  the  food  on  a 
second  plate  or  cup.  The  contrary  is  just  as  injurious,  and  it  is 
therefore  well  to  prepare  foods,  which  are  subject  to  rapid  cooling, 
in  vessels  with  double  bottoms,  filled  with  hot  water.  Concerning 
the  seasoning  of  the  dishes,  only  a  moderate  use  of  cooking  salt 
is  allowed,  and  other  spices  are  not  to  be  used  without  the  per- 
mission of  the  physician  ;  Wegele  strictly  forbids  the  use  of  citron 
or  pomegranate  skins  in  dietetical  cooking.  Water  which  is  to  be 
used  for  cool  drinks  should  best  be  boiled  and  then  be  allowed  to 
cool. 

Concerning  the  measures  used  in  the  following  chapter, — 

I  teaspoon  equals  about  five  gm., 
I  tablespoon  equals  about  15  gm., 
I  soup  plate  equals  about  250  gm., 
I  cup  equals  about  200  to  250  gm., 
I  wineglass  equals  about  150  gm., 

in  which  calculation  naturally  no  attention  has  been  paid  to  the 
specific  gravity  of  the  different  substances. 

I.  Drinks  and  Liquid  Foods. 

Barley  Soup  {Rijiger). — To  a  tablespoonful  of  pearl  barley 
washed  in  cold  water  add  two  or  three  lumps  of  sugar,  the  rind  of 
one  lemon,  and  the  juice  of  half  a  lemon.     On  these  pour  a  quart 


246  DRINKS    AND    LIQUID    FOODS. 

of  boiling  water,  and  let  the  mixture  stand  for  seven  or  eight  hours. 
Strain.  The  barley  water  should  never  be  used  a  second  time. 
Half  an  ounce  of  isinglass  may  be  boiled  in  the  water.  If  not 
needed  at  once,  these  barley  preparations  should  be  kept  in  the 
refrigerator,  and  warmed  when  required. 

Rice-water,  or  Mucilage  of  Rice  {Pavy). — Thoroughly  wash 
one  ounce  of  rice  with  cold  water.  Then  macerate  for  three  hours 
in  a  quart  of  water  kept  at  a  tepid  heat,  and  afterward  boil  slowly 
for  an  hour,  and  strain.  A  useful  drink  in  dysentery,  diarrhea,  and 
irritable  states  of  the  alimentary  canal.  It  may  be  sweetened  and 
flavored  in  the  same  way  as  barley  water. 

Lemonade  {Pavy). — Pare  the  rind  from  a  lemon  thinly,  and  cut 
the  lemon  into  slices.  Put  the  peel  and  sliced  lemon  into  a  pitcher 
with  one  ounce  of  white  sugar,  and  pour  over  them  one  pint  of 
boiling  water.  Cover  the  pitcher  closely,  and  digest  until  cold. 
Strain  or  pour  off  the  liquid. 

Beef-essence  {Yeo). — Cut  the  lean  of  beef  into  small  pieces, 
and  place  them  in  a  wide-mouthed  bottle  securely  corked,  and  then 
allow  it  to  stand  for  several  hours  in  a  vessel  of  boiling  water. 
This  may  be  given  in  teaspoonful  doses  to  infants  who  can  not  take 
milk,  and  in  larger  quantities  to  adults. 

Beef-tea  {Germain-See). — Meat  cut  into  small  pieces,  cold 
water  added,  and  then  gradually  heated  to  140°  or  160°  F,  Press, 
strain,  and  flavor  with  salt  and  pepper.  This  is  much  inferior  to 
the  preparations  made  with  hydrochloric  acid. 

Chicken  Broth  {Bartliolomezv). — Skin  and  finely  mince  a  small 
chicken  or  half  of  a  large  fowl,  and  boil  it,  bones  and  all,  with  a 
blade  of  mace,  a  sprig  of  parsley,  and  a  crust  of  bread,  in  a  quart 
of  water  for  an  hour,  skimming  it  from  time  to  time.  Strain 
through  a  coarse  colander. 

Chicken,  Veal,  or  Mutton  Broth  {Yeo). — Chicken,  veal,  or 
mutton  broth  may  be  made  like  beef-tea,  substituting  chicken,  veal, 
or  mutton  for  beef,  boiling  in  a  saucepan  for  two  hours,  and 
straining.  For  chicken  broth  the  bones  should  be  crushed  and 
added.  For  veal  broth  the  fleshy  part  of  the  knuckles  should  be 
used.  Either  may  be  thickened  and  their  nutritive  value  increased 
by  the  addition  of  pearl  barley,  rice,  vermicelli,  or  semolina. 

Mutton  and  Chicken  Broths  {Oslej-). — Mince  a  pound  of  either 
chicken  or  mutton,  freed  from  fat,  put  into  a  pint  of  cold  water,  and 
let  stand  in  a  cold  jar  on  ice  two  or  three  hours.     Then  cook  three 


DRINKS    AND    LIQUID    FOODS.  24/ 

hours  over  a  slow  fire,  strain,  cool,  skim  fat  off,  add  salt,  and  serve 
hot  or  cold.  Such  broth  is  much  better  than  any  manufactured 
meat  preparations.  Good  mutton  broth  is  difficult  to  make  on 
account  of  the  meat  containing  so  much  fat. 

Raw  Meat  Diet  [Ringer). — Use  two  ounces  of  rump  steak; 
take  away  all  fat,  cut  into  small  squares  without  entirely  separat- 
ing the  meat,  place  in  a  mortar,  and  pound  for  five  or  ten  minutes ; 
then  add  three  or  four  tablespoonfuls  of  water  and  pound  again  for 
a  short  time,  afterward  removing  all  sinews  or  fiber;  add  salt  to 
taste.  Before  using,  place  the  cup  or  jar  containing  the  pounded 
meat  in  hot  water  until  just  warm. 

Or  scrape  the  beefsteak  with  a  sharp  knife,  and  after  removing 
all  fat  and  tendon,  if  not  already  in  a  complete  pulp,  pound  in  a 
mortar.  Flavor  with  salt  and  pepper.  This  may  be  taken  in  the 
form  of  a  sandwich,  between  thin  bread  and  butter  or  mixed  with 
water  to  the  consistency  of  a  cream.  If  preferred,  the  meat  maybe 
rolled  into  balls  with  a  little  white-of-egg,  and  boiled  for  two  or 
three  minutes,  or  until  the  outside  turns  gray,  just  long  enough  to 
remove  the  raw  taste. 

Chicken  Jelly  {Adams). — Clean  a  fowl  that  is  about  a  year  old, 
remove  skin  and  fat ;  chop  fine,  bones  and  flesh,  in  a  pan  with  two 
quarts  of  water ;  heat  slowly,  skim  thoroughly,  simmer  five  to  six 
hours  ;  add  salt,  mace,  or  parsley  to  taste ;  strain  ;  cool.  When 
cool,  skim  off  the  fat. 

The  jelly  is  usually  relished  cold,  but  may  be  heated.  Give  often 
in  small  quantities. 

Milk-punch. — Make  by  adding  brandy  or  whiskey  or  rum  to 
milk  in  the  proportion  of  about  one  to  four  or  six  parts  of  milk  ; 
flavor  with  sugar  and  nutmeg  ;  shake  well. 

Sherry  or  Brandy  and  Milk  {Ringer). — To  one  tablespoonful  of 
brandy  or  one  wineglassful  of  sherry,  in  a  bowl  or  cup,  add  pow- 
dered sugar  and  a  very  little  nutmeg  to  taste.  Warm  a  breakfast 
cupful  of  new  milk  and  pour  into  a  pitcher.  Pour  the  contents 
from  a  height  over  the  wine,  sugar,  etc.      The  milk  must  not  boil. 

Junket  {Andersoii). — Sweeten  with  white  sugar  one  pint  of  good 
milk.  If  wine  is  allowed,  a  dessertspoonful  of  sherry  is  an  improve- 
ment. Heat  to  new  milk  warmth,  pour  into  a  shallow  dish,  and 
stir  in  two  teaspoonfuls  of  essence  of  rennet.  This  will  form  a 
slight  curd.  Grate  a  little  nutmeg  over  it,  or  add  a  pinch  of  pow- 
dered cinnamon.     Serve  when   quite  cold.     In  cold  weather  the 


248  DRINKS    AND    LIQUID    FOODS. 

milk  should  be  placed  in  a  warm  room  to  set.  An  excellent  food 
and  good  substitute  for  milk  in  typhoid  fever,  etc. 

Egg-nog. — Egg-nog  is  made  by  adding  the  beaten  yolk  of  egg 
and  a  little  spirits  to  a  tumblerful  of  milk,  stirring  well,  adding 
sugar  and  white  of  the  egg,  separately  beaten.  The  digestibility 
of  both  of  these  highly  nourishing  and  stimulating  preparations  is 
enhanced  by  the  addition  of  }4  of  an  ounce  of  lime-water,  which 
does  not  affect  the  taste. 

Egg  and  Wine  [Ruiger). — Take  one  egg,  y2  o{  3.  glass  of  cold 
water,  one  glass  of  sherry,  sugar,  and  a  very  little  nutmeg,  grated. 
Beat  the  egg  to  a  froth  with  a  tablespoonful  of  cold  water.  Make 
the  wine  and  water  hot,  but  not  boiling;  pour  on  the  egg,  stirring 
all  the  time.  Add  sufficient  sugar  to  sweeten,  and  a  very  little  nut- 
meg. Put  all  into  a  porcelain-lined  saucepan  over  a  gentle  fire,  and 
stir  one  way  till  it  thickens,  but  do  not  let  it  boil.  Serve  in  a  glass, 
with  crisp  biscuits  or  sippets  of  toast. 

Milk  for  Pudding  or  Stewed  Fruit  {Ringer). — Boil  a  strip  of 
lemon  and  two  cloves  in  a  pint  of  milk  ;  mix  ^  of  a  teaspoonful  of 
arrowroot  in  a  little  cold  milk  and  add  it  to  the  boiling  milk;  stir  it 
until  about  the  consistency  of  cream.  Have  ready  the  yolks  of 
three  eggs  beaten  up  well  in  a  little  milk.  Take  the  hot  milk  off 
the  fire,  and  as  it  cools  add  the  eggs  and  a  teaspoonful  of  orange- 
flour  water,  stirring  it  constantly  till  quite  cool.  Keep  it  in  a 
very  cool  place  until  required  for  use. 

Arrowroot  Blancmange  [Ringer). — Take  two  tablespoonfuls  of 
arrowroot,  ^  of  a  pint  of  milk,  lemon,  and  sugar  to  taste. 

Mix  the  arrowroot  with  a  little  milk  to  a  smooth  batter ;  put  the 
rest  of  the  milk  on  the  fire  and  let  it  boil,  sweeten  and  flavor  it, 
stirring  all  the  time  till  it  thickens  sufficiently.  Put  into  a  mold 
until  quite  cold. 

KvTowTOOt{Pavy). — Mix  thoroughly  two  teaspoonfuls  of  arrow- 
root with  three  tablespoonfuls  of  cold  water,  and  pour  on  them 
^  of  a  pint  of  boiling  water,  stirring  well  meanwhile.  If  the  water 
is  quite  boiling,  the  arrowroot  thickens  as  it  is  poured  on,  and 
nothing  more  is  necessary.  If  only  warm  water  is  used,  the  arrow- 
root must  be  boiled  afterward  until  it  thickens.  Sweeten  with  loaf 
sugar,  and  flavor  with  lemon-peel  or  nutmeg,  or  add  sherry,  port 
wine,  or  brandy  if  required.  Boiling  milk  may  be  employed  instead 
of  water,  and  when  this  is  done  no  wine  must  be  added,  as  it  would 
otherwise  curdle. 


DIETETIC    LIQUID    FOODS    AND    DRINKS.  249 

Oatmeal  Gruel  (Plain). — Two  tablespoonfuls  of  oatmeal,  one 
saltspoonful  of  salt,  one  scant  teaspoonful  of  sugar,  one  cup  of 
boiling  water.  Cook  for  thirty  minutes  ;  then  strain  through  a  fine 
wire  strainer  to  remove  the  hulls, place  again  on  the  stove,  add  the 
milk,  and  heat  just  to  the  boiling  point.     Serve  hot. 

Farina  Pudding  (U.  S.  Army  Hospital  Recipe  for  12  Men). 
— Farina,  yi  of  a  pound;  milk,  two  pints  ;  water,  one  pint;  sugar, 
2^  ounces;  eggs,  four  ounces;  nutmeg,  yi  of  an  ounce. 

Directions. — Put  the  water  into  a  stewpan  with  a  little  salt. 
When  it  boils  stir  in  the  farina.  Let  it  boil  twenty  minutes.  Stir  in 
the  milk,  which  must  be  hot.  Beat  the  eggs  until  they  are  very 
light;  mix  the  sugar  with  them.  Stir  in  the  eggs  and  sugar  with 
the  farina.  Add  the  spice.  Pufit  into  a  moderate  oven  and  bake 
a  half  or  three-quarters  of  an  hour. 

Port-wine  Jelly  [Ringer). — Put  into  a  jar  one  pint  of  port-wine, 
two  ounces  of  gum  arable,  two  ounces  of  isinglass,  two  ounces  of 
powdered  white  sugar-candy,  14  of  a  nutmeg,  grated  fine,  and  a 
small  piece  of  cinnamon.  Let  this  stand  closely  covered  all  night. 
The  next  day  put  the  jar  into  boiling  water  and  let  it  simmer  until 
the  contents  are  dissolved,  then  strain,  let  stand  till  cold,  and  then 
cut  into  small  pieces  for  use. 

Nutritious  Coffee  {Ringei'). — Dissolve  a  little  isinglass  in  water, 
and  then  put  ]/,  of  an  ounce  of  freshly  ground  coffee  into  a  sauce- 
pan with  one  pint  of  new  milk,  which  should  be  nearly  boiling 
before  the  coffee  is  added  ;  boil  both  together  for  three  minutes. 
Clear  it  by  pouring  some  of  it  into  a  cup  and  dashing  it  back  again, 
add  the  isinglass,  and  let  it  settle  on  the  hob  for  a  few  minutes. 
Beat  up  an  Q^'g  in  a  breakfast  cup  and  pour  the  coffee  upon  it;  if 
preferred,  drink  it  without  the  &gg. 

Glair-water. — Into  200  c.c.  of  cold  water  which  has  previously 
been  boiled,  put  with  constant  stirring  the  white  of  one  ^%g,  and 
add,  according  to  prescription,  three  teaspoonfuls  of  powdered 
sugar,  or  grape-sugar,  or  ten  gm.  of  cognac.  The  white  of  an  ^gg 
equals  about  12  calories;  15  gm.  of  sugar  equals  about  50  calories; 
ten  gm.  of  cognac  equals  50  calories. 

Kefyr. — It  is  best  to  procure  moist  kefyr  mushrooms  (not  the 
dried  grains)  prepared  for  immediate  use.  They  can  be  pro- 
cured from  the  Caucasian  Kefyranstalt  in  Breslau,  or  from  Dr.  M. 
Lehmann,  Berlin  C.  (43  and  44  Heiligegeist  Strasse).  Pour  away 
the  liquid  contained  in  the  bottle,  wash  the  mushrooms  in  a  luke- 
17 


250  DIET    LISTS. 

warm  (about  15°  R.  or  18.7°  C.)  soda  solution  of  5  :  1000,  rinse  with 
clean  lukewarm  water,  and  after  pouring  away  the  water  place  the 
mushrooms  in  a  vessel  of  porcelain  or  Bunglan  clay  of  two  liters' 
capacity.  Previously  two  liters  of  milk  should  have  been  boiled 
and  allowed  to  cool  again.  Now  pour  the  milk,  whose  tempera- 
ture should  be  about  15°  R.  or  18.7°  C,  upon  the  mushrooms, 
close  the  vessel  tightly,  and  let  it  stand  twenty-four  hours  in  a  place 
whose  temperature  is  13°  to  15°  R.  or  18.7°  C.  (in  summer  in  the 
cellar),  during  which  time  it  is  expedient  to  often  stir  the  milk  care- 
fully. At  the  expiration  of  this  time  it  should  be  stirred  again,  and 
the  milk  is  then  poured  through  a  moderately  fine  wire  sieve  into 
thoroughly  cleaned  bottles  with  patent  stoppers.  These  bottles 
are  again  to  be  kept  twenty-four,  thirty-six,  forty-eight,  or  at  the 
highest  fifty-four  hours  (according  as  kefyr  one,  two,  three,  or  four 
days  old  has  been  prescribed)  in  a  place  whose  temperature  is  kept 
at  about  15°  R.  or  18.7°  C,  lying,  not  standing  up,  and  are  then 
ready  for  use. 

By  frequent  shaking,  the  process  of  fermentation  may  be  has- 
tened, likewise  through  heat,  on  which  account  the  fermentation 
takes  place  more  quickly  in  midsummer,  and  the  kefyr  conse- 
quently will  be  finished  sooner.  The  mushrooms  which  remained 
in  the  sieves  after  pouring  off  the  milk  into  the  patent  flasks  must 
each  time  be  rinsed  with  lukewarm  water  and  freed  from  particles 
of  cheese,  and  afterward  placed  again  in  the  thoroughly  clean  porce- 
lain vessel,  and  milk  is  then  again  poured  upon  them.  After  two 
or  three  days  the  preparation  is  so  regulated  that  each  day  two 
bottles  (of  one  liter  each)  become  ready  for  use,  for  which  reason 
four  patent-stoppered  bottles  are  necessary.  Once  a  week  the 
bottles  must  be  rinsed  with  a  lukewarm  soda  solution  of  5  :  looo 
instead  of  with  lukewarm  water,  in  order  to  free  them  from  acid. 
At  first  let  the  patient  drink  one  wineglassful  two  or  three  times  a 
day,  then  ^  of  a  liter,  and  constantly 'increase  the  quantity  until 
the  prescribed  dose  has  been  reached.  One  hundred  gm.  of  kefyr 
equal  about  45  calories. 

Almond  Milk. — Thirty  grs.  of  sweet  almonds  and  two  bitter 
almonds  are  blanched  after  they  have  lain  twenty-four  hours  in 
cold  water.  One  can  also  scald  the  almonds  with  boiling  water ; 
then  they  can  be  easily  pressed  out  of  their  hulls  after  a  few 
minutes.  The  almonds  are  either  ground  in  a  mill  or  pounded  in 
a  mortar,  then  mixed  with  ^  of  a  liter  of  warm  water  or  warm  milk, 


MEAT    EXTRACTS,    BOUILLON,    ETC.  25  I 

and  the  mixture  is  allowed  to  stand  two  hours,  after  which  it  is 
strained  through  a  cloth  and  the  juice  well  pressed  out. 

Thirty  grs.  of  almonds  equal  200  calories;  250  gm.  of  milk 
equal  170  calories. 

Extract  of  Meat  [according  to  IVte/),  "  Succus  carnis  recenter 
expressus." — Meat  free  from  fat  is  chopped  fine,  arranged  in  several 
layers,  which  are  separated  by  coarse  (filter)  linen,  and  subjected 
to  pressure  in  a  colander;  the  juice  is  given  pure  (as  medicine) 
by  the  teaspoonful,  or  also  diluted  with  beef-tea,  but  must  not  be 
subjected  to  a  temperature  higher  than  50°  R.  or  62.5°  C,  for 
otherwise  the  albuminous  parts  contained  in  it  would  coagulate. 
"Valentine's  meat  juice"  (extract)  may  serve  as  a  good  sub- 
stitute for  the  fresh  extract  of  meat  particularly  prepared.  A 
teaspoonful  of  this  preparation  is  diluted  with  one  to  two  table- 
spoonfuls  of  cold,  or,  at  the  most,  lukewarm,  water;  the  yolk  of 
one  egg  may  also  be  added. 

Meat  Extract  Ice  {according  to  v.  Zienissen). — One  k.  of  fresh 
beef  is  cut  into  pieces  the  size  of  a  hand,  and  is  wrapped  in  coarse 
lattice-like  linen,  put  under  a  lever-press  and  slowly  pressed;  this  is 
best  done  by  an  apothecary.  The  juice  is  caught  in  a  porcelain 
dish.  In  this  way  one  gets  about  500  gm.  This  is  mixed  with 
250  gm.  of  sugar  and  20  gm.  of  freshly  pressed  lemon  juice  (though 
this  had  better  be  omitted  for  dyspeptics),  and  20  gm.  of  cognac, 
containing  extract  of  vanilla,  which  has  been  well  stirred  with  the 
yolks  of  three  eggs,  is  added,  and  the  whole  is  placed  in  a  freezer. 

Bottled  Bouillon  [according  to  Uffelniann). — Three  hundred 
gm.  of  fresh,  lean  meat  are  cut  into  small  blocks,  and  without  any 
addition  is  put  into  a  clean  bottle  with  wide  mouth.  This  is  closed, 
if  there  be  no  suitable  stopper,  with  a  stopper  of  pure,  sterilized 
cotton,  and  placed  in  a  vessel  of  warm  water,  slowly  heated,  and 
the  water  should  be  allowed  to  boil  one-half  hour.  The  bottle 
which  is  now  to  be  taken  out  contains  about  100  gm.  of  a  turbid 
brown  broth,  which  is  poured  off  without  straining. 

Simple  Bouillon,  or  Beef-tea. — One-half  of  a  k.  of  lean  beef 
is  cut  into  small  pieces,  put  into  a  pot  holding  about  three  liters, 
with  a  well-fitting  cover,  or  into  a  steam  cooking  apparatus.  This 
is  to  be  filled  with  cold  water,  and  the  meat  to  be  boiled  three  to 
four  hours.  According  as  the  bouillon  is  desired  concentrated  or 
dilute,  the  liquid  which  evaporates  must  be  replaced  by  the  addi- 
tion of  boiling  water.    Finally,  one  obtains  about  two  liters  of  bouil- 


z^z 


DIET    LISTS. 


Ion,  and  the  meat  which  remains  is  of  no  further  use.  To  obtain 
greater  palatabiHty  and  a  prettier  color,  the  meat  may  be  first 
browned  in  a  little  hot,  pure  lard  before  cooking,  fresh  soup  heibs 
or  a  handful  of  dried  Knorr's  julienne  added,  then  finally  add  the 
three  liters  of  cold  water. 

Meat  Jelly  {according  to  Hepp). — Good  beef,  free  from  fat  and 
bones,  is  cooked  on  the  waterbath  with  a  little  water  for  sixteen 
hours,  until  it  congeals  into  jelly.  Often  one  is  compelled  to  use 
artificial  preparations  in  the  making  of  bouillon  or  in  strengthen- 
ing weak  bouillon.  The  most  reliable  in  this  respect  is  Liebig's 
extract  of  meat  (about  ten  c.c.  to  250  gm.),or  Cibil's  bouillon  (one 
tablespoonful  to  250  gm.) ;  \-ery  convenient  also  are  Quaglio's 
bouillon  capsules.  If  at  the  same  time  one  wishes  to  give  to  the 
bouillon  an  increased  nutritive  value,  one  can  add  one  teaspoonful 
of  meat  peptone;  or  either  Mosquera  Julia  beef  meal,  Armour's 
vigoral,  or  Valentine's  meat  juice  may  be  used. 

A  preparation  Avhich  is  often  of  ser\'ice  is  Leube-Rosenthal's 
meat  solution.  One  k.  of  beef  is  chopped  fine,  put  into  a  vessel 
with  one  liter  of  water  and  20  gm.  of  pure  hydrochloric  acid,  which 
vessel  is  put  in  a  Papin's  steam  cooking  apparatus,  in  which  it 
should  boil  ten  to  fifteen  hours  (with  frequent  stirring).  After  this 
the  mass  is  put  into  a  mortar  and  ground  to  an  emulsion.  After 
a  further  cooking  of  fifteen  hours  with  bicarbonate  of  soda,  it 
becomes  neutral,  and  is  then  steamed  to  a  consistenc}-  of  mush, 
and  put  into  four  cans,  which  are  to  be  soldered.  As  the  making 
of  this  preparation  requires  much  time  and  particular  care,  it  is 
advisable  to  procure  it  from  one  of  the  following  firms,  who  put  it 
upon  the  market  in  cases  of  3^  k.  (enough  for  an  adult  for  one 
day) :  Armour  &  Co.,*  Parke,  Davis,  &  Co.,"!"  Dr.  j\Iirus'sche  Hof- 
apotheke  (R.  Stutz),t  Huffiier's  Hof-  und  Ratsapotheke  (R.  Wahr- 
burg),t   C.  Reinhardt  (formerly  Charrier).  § 

Soups  with  Fillers. 

{a)  Soups  zi'itli  Fillers  from  the  Cereal  Kingdom. — The  grains  in 
q'uestion  (such  as  barley,  or  peeled  barley,  oats,  green  corn,  rice) 
should  be  softened  the  night  before  in  cold  water,  in  which  they 
are  to  remain  until  the  following  forenoon.  Then  the  water  is 
poured  off  and  the  grains  are  put  on  the  fire  with  weak,  cold 
bouillon,  where    they  should  be  kept  boiling  at  least  three   hours; 

*  Chicago.     7  Detroit,  Mich.     J  Jena.     |  Berlin  W.,  27  Behren  Strasse. 


PREPARATION    OF    SOUPS    WITH    FILLERS.  253 

one-half  hour  before  serving,  the  soup  is  strained  through  a  fine  hair 
sieve,  and,  after  the  addition  of  a  httle  meat  extract,  is  made  to 
boil  again;  salt  is  then  added  as  required,  and  to  one  plate  of  soup 
the  yolk  of  one  egg  may  be  added.  If  one  is  to  prepare  a  single 
plate  of  such  soups,  the  soup  meals  of  Knorr  in  Heilbronn  are  very 
serviceable,  although  they  do  not  become  gelatinous  like  the  soups 
prepared  from  whole  grains,  and  are  not  as  appetizing.  These 
meals  must  be  stirred  with  cold  bouillon  to  a  thin  liquid  mass, 
and  allowed  to  run  into  boiling  beef-tea,  which  after  that  must 
boil  at  least  one  to  two  hours  longer.  Twenty  gm.  of  meal  is 
calculated  for  one  plate  of  soup.  In  serving,  one  can  add  also 
the  yolk  of  an  egg.  The  nutritive  value  of  these  soups  may  be 
considerably  increased  by  the  addition  of  aleuronat  flour.  It  is 
best  to  take  eight  gm.  of  aleuronat  flour  and  16  gm.  of  oat-  or  green 
corn  meal  for  one  plate  of  soup.*  The  aleuronat  meal  is  mixed 
with  cold  water  (or  beef-tea),  and  is  only  added  to  the  soup  after 
the  latter  has  boiled  one-half  hour.  The  meal  swells  hardly  at  all, 
and  for  that  reason  more  of  the  two  flours  is  to  be  taken  than  is 
necessary,  ordinarily,  in  making  of  soup.  Soups  prepared  with  20 
gm.  of  oat  meal,  or  leguminose  meal,  barley  meal,  tapioca,  rice,  etc., 
have  a  combustion  value  of  about  70  to  75  calories,  which  is  in- 
creased about  60  calories  by  the  addition  of  the  yolk  of  one  egg. 

ib)  Tapioca  Soup. — For  this  soup  the  French  tapioca  of  N.  &  J. 
Bloch  in  Paris,  and  Knorr  in  Heilbronn,  had  best  be  used,  which 
can  be  had  in  most  of  the  larger  fancy  groceries  in  packages  of 
250  gm.  For  one  plate  of  soup  a  heaped  teaspoonful  of  these 
grains  is  boiled  for  half  of  an  hour  with  beef-tea,  which  has  been 
boiling  for  some  time  previous,  and  to  this,  after  a  quarter  of  an 
hour,  a  little  extract  of  meat,  sufficient  to  cover  the  point  of  a 
knife,  is  added  ;  if  this  be  added  later,  just  before  serving,  the  taste 
of  the  extract  is  easily  distinguished,  which  is  disagreeable  to  many 
patients. 

{c)  Sweetbread  Soup. — The  sweetbread  is  soaked  for  one  hour  in 
cold  water,  which  is  during  this  time  often  to  be  renewed  ;  then  it  is 
boiled  in  slightly  salted  beef-tea  or  salt  water  for  one  hour,  to  which 
one  may  add  one  teaspoonful  of  julienne  for  improving  the  flavor. 
After  it  is  cooked  completely  soft,  it  is  taken  out  of  the  beef-tea 
and   freed   from  all  skins,  blood-vessels,  etc.     Now   it  can  be  cut 

*Can  be  procured  from  Dr.  Hundhausen's  Starkefabrik,  Hamm  in  Westfalen  ;  4^  k. 
cost  seven  marks,  C.  O.  D.  .  • 


2  54  DIET    LISTS. 

either  in  pieces  the  size  of  a  walnut,  which  one  lays  on  the  soup 
plate  and  then  pours  over  the  beef-tea,  or  the  sweetbread  can  be 
forced  through  a  fine  sieve  ;  beef-tea  is  poured  over  the  mass  and 
the  whole  is  again  put  on  the  fire  until  it  boils,  after  which  the 
soup  may  be  served.  The  latter  proceeding  is  rather  to  be  recom- 
mended in  the  case  of  dyspeptics.  One  hundred  gm.  of  sweet- 
bread (raw)  is  equivalent  to  about  90  calories. 

[d)  Brain  Soup. — A  calf's  brain  is  allowed  to  lie  in  water  (cold) 
for  one  hour,  in  order  to  draw  out  the  blood  contained  in  it ;  then 
the  water  is  poured  off,  the  brain  is  once  more  thoroughly  washed 
and  cooked  in  weakly  salted  beef-tea  or  salt  water  with  the  addition 
of  one  teaspoonful  of  julienne,  for  one  hour.  Then  immediately 
force  it  through  a  fine  sieve,  dilute  the  mush  with  beef-tea  and  cook 
it  again.  In  serving,  the  yolk  of  an  egg  may  be  added.  One  hun- 
dred gm.  of  calf's  brain  equal  140  calories. 

{e)  Soup  Containing  Meat  {according  to  Professor  M.  Rosenthal^. — 
Scraped  raw  beefsteak  is  chopped  fine,  forced  through  a  sieve,  the 
mass,  soft  as  butter,  is  thoroughly  mixed  with  the  yolk  of  an  egg, 
and  mixed  in  minute  particles  to  a  greater  or  less  degree  with 
boiling  soup. 

(/")  Meat  Puree  Soup  {according  to  Hedivig  Heyl).  —  Twenty 
gm.  of  grated  rolls  are  cooked  for  one-quarter  of  an  hour  with 
^  of  a  liter  of  bouillon.  Stewed  chicken  meat  is  pounded  fine, 
passed  through  a  hair  sieve,  and  25  gm.  of  it  are  stirred  together 
with  one  tablespoonful  of  cream  or  one  teaspoonful  of  meat  peptone, 
several  spoonfuls  of  soup  are  added,  and  now  beaten  up  with  the 
entire  mass,  and  served  without  further  cooking. 

{g)  Roll  Soup  {according  to  Hedwig  Heyl). — Thirty  gm.  of  grated 
rolls  are  roasted  with  ten  gm.  of  butter,  without  coloring  the  latter, 
^  of  a  liter  of  bouillon  is  poured  over  and  slowly  boiled  for 
half  an  hour.  The  yolk  of  an  egg  is  beaten  up  with  a  tablespoon- 
ful of  sweet  or  sour  cream,  and  then  put  into  the  soup,  and  the  latter 
is  passed  through  a  sieve  upon  the  previously  warmed  plate  (equal 
to  about  240  calories). 

{h)  Soup  Bisctnt. — Forty  gm.  of  butter  are  stirred  for  one-quarter 
of  an  hour,  afterward  mixed  with  two  whole  eggs,  a  little  salt  is 
added,  and  at  last  40  gm.  of  flour.  In  order  to  make  the  mass 
rise  more  easily,  one  can  add  three  gm.  of  baking  powder  (consist- 
ing of  bicarbonate  of  soda  and  tartaric  acid,  which  can  be  had  in 
most  drug  stores  in  packages  of  30  gm.).     A  long   square  sheet 


SELECTION   AND    PREPARATION    OF    FISH.  255 

iron  mold  is  rubbed  with  butter,  the  mass  is  put  into  it  and  baked 
in  the  oven  with  moderate  heat  for  half  an  hour.  When  the 
biscuit  has  cooled  off,  it  is  taken  out,  cut  into  blocks  and  can  then 
be  added  to  the  various  soups  (such  as  sweetbread,  brain,  or  pea 
soup).     The  whole  mass  corresponds  to  about  630  calories. 

(i)  Noodle  Soup  ( Vermicelli  Soup). — The  noodles  (only  the  best 
quality)  must  be  boiled  half  an  hour  in  very  good  bouillon.  A 
soup  of  about  ten  gm.  of  vermicelli  equals  about  50  calories. 

{k)  Butter  Dumpling  Soup. — Thirty  gm.  of  butter  is  stirred  one- 
quarter  of  an  hour,  one  whole  o.^^  and  a  little  salt  being  added  ;  stir 
the  same  and  mix  well  with  the  butter,  and  then  add  30  gm.  of 
flour.  With  a  teaspoon  rather  long  lumps  are  cut  out  of  the 
dough  and  put  into  boiling  beef-tea,  in  which  they  must  boil 
twenty  minutes  more  on  a  fire  not  too  strong.  The  whole  mass 
equals  about  420  calories. 

(/)  Green  Pea  Soup  {Leashed). — Fresh  green  peas  are  boiled  in 
saltwater  until  thoroughly  soft ;  in  advanced  seasons  when  they 
are  no  longer  very  young,  add  ^^  of  a  gm.  of  carbonate  of  soda ; 
canned  peas  are  also  very  good  at  any  time  for  making  this  soup. 
Let  the  water  run  off  through  a  strainer,  force  the  peas  through  a 
fine  sieve,  mix  with  a  teaspoonful  of  flour  (aleuronat  flour),  pour 
beef-tea  over  the  mass  and  cook  again;  100  gm.  of  peas  equal 
75  calories;  ^/^  of  a  liter  (420  gm.)  of  peas  gives  280  gm.  of 
mashed,  equal  to  300  calories. 

II.  Fish. 

Fish  for  the  table  of  a  sick  person  should  never  be  boiled  or  fried 
in  fat,  but  only  boiled  in  water.  Of  the  fresh-water  fish  the  trout, 
the  perch-pike  (Lucioperca  sandra),  pike,  carp,  grayling,  and  salmon 
come  under  consideration  here.  Of  salt-water  fish  the  black-  or 
sea-bass,  sea-trout,  the  bluefish  (Pomatomus  saltatrix),  the  mack- 
erel, cod,  rockfish,  and  haddock  are  suitable.  The  fish  is  carefully 
freed  from  scales,  rubbed  inside  with  salt,  and  boiled  in  very  strongly 
salted  boiling  water,  in  which  it  is  allowed  to  remain,  according  to 
size,  from  one-quarter  to  one-half  hour  ;  all  spices  are  to  be  omitted, 
only  a  handful  of  dried  julienne  may  be  put  in  the  boiling  water, 
by  which  the  flavor  is  considerably  increased.  All  fat  and  pungent 
sauces  are  to  be  avoided,  and  even  hot  butter  will  generally  not 
agree  with  the  dyspeptic,  so  that  it  is  best  to  put  only  a  little 
fresh  butter  on  the  fish  when  serving.     Of  the  sea  fish,  the  cod, 


256  DIET    LISTS. 

rose-fish,  and  haddock  are  to  be  recommended.  Their  preparation 
is  the  same,  except  that  they  are  soaked  one-quarter  of  an  hour 
previously  in  fresh  water  (not  in  boiling,  but  cold  water),  in 
which  is  put  a  large  quantity  of  salt  and  also  some  julienne.  The 
vessel  must  be  large  enough  to  allow  the  fish  to  be  surrounded  on 
all  sides  by  the  water.  A  two-  or  three-pound  haddock  must 
remain  on  the  fire  thirty  to  forty  minutes  to  be  thoroughly  done ; 
sea  fish  also  are  to  be  served  with  fresh  butter. 

III.  Meats. 

1.  Sirloin  [Fillet). — For  the  tenderness  of  beef  it  is  of  import- 
ance that  it  be  allowed  to  hang  long  enough  ;  for  this  two  to  four 
days  are  necessary  in  summer,  in  winter  as  many  as  eight  days  ; 
only  in  the  coldest  season  it  must  be  protected  from  frost, 
through  which  it  becomes  very  dry.  The  meat  is  freed  from 
all  fat  and  membranous  parts,  well  beaten,  washed  and  salted,  and 
thus  put  into  a  stewpan  with  hot  lard,  in  which  it  is  quickly 
turned  over  several  times.  The  meat  loses,  in  roasting  in  the 
English  style,  ten  per  cent,  in  weight,  and  in  slow  roasting,  30  per 
cent,  in  weight.  To  prepare  a  fillet  in  English  style,  so  that  it  is 
still  red  inside,  one  calculates  for  each  pound  of  meat  one-quarter 
of  an  hour,  so  that  a  four-pound  roast  requires  one  hour's  roasting. 
It  is  entirely  unsuitable  to  try,  by  means  of  sticking  with  a  fork, 
how  far  the  roast  is  done,  for  much  juice  is  lost  by  this,  and  the 
cook  must  learn  by  practice,  by  the  nature  of  the  pan,  the  thick- 
ness of  the  roast,  the  strength  of  the  fire,  to  calculate  the  period  of 
time  necessary  for  the  completion  of  the  roast.  During  roasting 
frequently  add  spoonfuls  of  beef-tea,  so  that  the  butter  does  not 
become  too  dark,  but  the  bouillon  must  never  be  poured  upon  the 
meat  itself.  One-quarter  of  an  hour  before  serving,  the  roast  is 
taken  out  of  the  pan,  all  fat  is  carefully  skimmed  from  the  sauce, 
a  tablespoonful  of  white  flour  and  a  teaspoonful  of  aleuronat  flour 
are  mixed  with  a  little  cold  bouillon,  a  little  extract  of  meat  is 
added,  and  this  thin  mixture  is  then  added  to  the  sauce  of  the 
roast,  which  is  again  made  to  boil,  and  the  roast  is  again  laid  into 
it  until  serving.  One  hundred  gm.  of  beef  roasted  in  English 
style  equal  about  210  calories. 

2.  Roast  Beef. — This  roast  is  only  good  and  juicy  when  in  large, 
thick  pieces  ;  the  preparation  is  exactly  the  same  as  the  preceding. 
It  is  juicier  when  roasted  on  the  spit,  though  in  most   households 


PREPARATION    OF    MEATS.  257 

the  necessary  equipments  are  wanting.  With  this  meat,  which  has 
a  tolerably  coarse  grain,  a  sufficient  time  for  hanging  is  absolutely 
necessary. 

3.  Raw  Beefsteak  {according  to  Letibe). — From  the  loin,  which 
has  hung  a  sufficient  time,  as  much  meat  is  scraped  off  with  a  dull 
spoon-handle  as  can  be  separated  without  violence,  until  one  has  a 
mass  of  about  150  gm.  The  mass  thus  scraped  off  is  slightly 
salted,  made  into  a  very  small  cake,  and  eaten  either  entirely  raw 
or  just  roasted  on  the  surface  in  fresh  butter.  One  hundred  gm. 
equal  about  120  calories. 

4.  Beefsteak  [according  to  Wiet). — Take  some  of  the  best  sirloin 
and  cut  across  a  piece  as  thick  as  a  thumb  ;  after  this  has  been 
well  pounded  and  slightly  salted  on  one  side,  it  is  put  into  an  iron 
or  enameled  pan,  fried  for  one  minute  on  one  side  in  fresh  butter, 
then  turned,  gravy  poured  over,  and  is  fried  on  the  other  side  only 
one-half  of  a  minute,  after  which  it  is  immediately  served  on  a 
warmed  plate.     One  hundred  gm.  equal  about  130  calories. 

5.  Beefsteak  in  Oil. — From  a  well-hung  fillet  a  piece  as  thick  as 
a  thumb  is  cut,  all  skins  and  fat  removed,  the  same  well  pounded, 
and  salted.  Then  spread  on  both  sides  with  the  finest  olive  oil, 
cover  up  well  and  allow  it  to  remain  thus  two  hours.  Thereafter 
put  into  the  pan  and  fry  without  any  further  grease  (except  the  oil 
previously  spread  over  it)  till  it  is  brown  on  both  sides.  The 
time  necessary  for  frying  varies  from  five  to  ten  minutes,  according 
to  the  degree  one  wishes  it  done  inside. 

6.  Roast  Veal. — The  leg  of  veal,  after  it  has  hung  a  sufficient 
time,  is  freed  from  the  thick  outside  skin  and  laid  in  sweet  milk  for 
one  or  two  days  in  summer,  two  or  four  days  in  winter,  by  which 
it  becomes  tender  and  soft.  Before  using,  it  is  carefully  washed, 
thoroughly  skinned,  and  well  salted;  thereupon  it  is  larded  with 
fresh  lard  and  roasted  in  tolerably  hot  butter  or  white  beef  fat,  of 
which  about  200  gm.  are  necessary.  For  the  rest  it  is  treated  like 
any  other  roast,  except  that  it  is  best  in  the  case  of  veal  to  roast 
until  well  done,  which  for  a  small  roast  takes  two  hours,  for  a  large 
one,  three  hours.  In  the  English  way  one  and  one-quarter  to  two 
hours  are  sufficient.  Roast  veal,  when  the  bone  is  not  previously 
taken  out,  gives  a  very  good,  thick  sauce,  so  that  in  most  cases  it 
is  necessary  to  add  only  a  little  bouillon  after  the  fat  has  been 
skimmed  off.  Its  value  in  calories  is  about  the  same  as  that  of 
lean  beef. 


258  DIET    LISTS. 

7.  Veal  fncandcaii  is  also  laid  in  milk  a  few  days  before  using, 
which  milk  it  is  best  to  let  sour,  for  the  flavor  is  thus  increased  ; 
it  must  be  done,  however,  in  such  a  manner  that  the  milk  covers 
the  meat  completely.  For  the  rest,  the  meat  is  treated  as  any 
other  veal  roast,  except  that  one  and  a  half  hours'  roasting  with 
a  good  fire  will  suffice.  The  sauce  is  to  be  mixed  with  flour,  and 
it  can  be  given  a  piquant  flavor  by  the  addition  of  some  cream. 

8.  Veal  Cutlets  {^Cliops). — The  ribs  of  the  calf  are  separated  from 
the  backbone ;  the  single  cutlets  separated  from  each  other  are 
washed  and  freed  from  skins,  pounded,  salted,  and  fried  in  a  pan 
with  hot  butter  ;  they  will  be  more  tender  if  they  have  lain  one  day 
previously  in  milk  ;  in  this  case  they  need  be  fried  only  eight  or 
ten  minutes,  but  otherwise  it  is  preferable  to  fry  them  from  one- 
half  to  one  hour,  not  leaving  them  long  in  one  place, often  shoving 
them  to  and  fro,  during  which  time  a  piece  of  fresh  butter  is  also 
added,  and  the  melted  butter  is  constantly  poured  over  the  cutlets  ; 
before  serving,  some  good  liquor  from  a  roast  is  added.  To  cover 
cutlets  with  bread  crumbs  is  not  advisable  in  dietetic  cooking. 
One  hundred  gm.  of  fried  veal  cutlets  (also  the  following  veal 
dishes)  equal  230  calories. 

9.  Scotched  Collop. — From  the  leg  of  v^eal,  which  has  lain  in  milk 
two  or  three  days,  cut  slices  as  thick  as  your  thumb,  wash,  beat, 
and  salt  them,  and  put  them  in  a  pan  with  hot  butter,  where  they 
must  be  allowed  to  brown  slightly  on  both  sides.  Then  pour  in 
one  glass  of  white  wine  and  some  bouillon,  cover  up  tightly,  and 
let  them  steam  altogether  for  about  one  and  a  quarter  hours,  pour- 
ing in  some  bouillon  from  time  to  time.  The  addition  of  sour 
cream  improves  the  flavor.  But  the  digestibility  is  decreased  by 
the  sour  cream.  Then  skim  off  all  fat  and  with  flour  prepare  a 
sauce  as  directed  above. 

10.  Fillet  of  Veal. — From  the  fricandeau  piece  cut  strips  one  cm. 
thick  and  six  cm.  wide,  and  prepare  them  exactly  as  in  No.  9  ;  in  the 
middle  lay  a  few  pieces  of  middling,  roll  them  up  and  tie  with  cord. 
For  the  rest  proceed  exactly  as  in  the  case  of  scotched  collop. 

1 1.  Veal  Steak. — Cut  from  the  leg  pieces  as  thick  as  your  thumb, 
weighing  about  lOO  gm.,  pound  them  well,  wash,  salt,  and  lay  them 
in  a  pan  with  hot  butter,  and  fry  them,  with  frequent  turning,  for 
ten  minutes.  Either  add  some  sauce  from  a  roast,  or  prepare  one 
from  bouillon,  flour,  and  meat  extract,  which  is  put  into  the  pan, 
and  then  let  the  steaks  fry  in  it  for  two  minutes  longer. 


PREPARATION  OF  FOWL,  POULTRY,  ETC.  259 

12.  Lajub's  Saddle. — The  saddle  of  a  young  animal  is  laid  in 
milk  for  two  days,  or  the  milk  is  allowed  to  sour,  through  which  a 
venison-like  flavor  is  obtained.  Before  using,  the  roast  is  washed, 
freed  from  fat  and  skins,  and  larded  with  fresh,  unsmoked  bacon  ; 
then  it  is  put  into  a  pan  with  previously  heated  beef  fat  or  good 
butter,  in  which  it  must  immediately  be  turned  several  times.  It 
is  roasted  one  and  a  half  hours,  during  which  time  it  is  to  be  dili- 
gently basted  by  the  addition  of  beef-tea.  In  the  last  hour  pour 
in  one  glass  of  white  wine  and  as  much  bouillon  as  the  sauce  has 
boiled  down.  With  sour  cream  the  roast  becomes  particularly 
well  flavored,  but  not  every  patient  can  stand  it.  The  sauce  is  pre- 
pared as  in  other  roasts  with  flour. 

13.  Roast  Foivl. — Fowl  destined  for  roasting  must  be  picked  and 
cleaned  immediately  after  killing,  and  then  it  is  allowed  to  hang  in 
a  cool  place  at  least  one  day  ;  in  winter,  two  to  four  days,  for  which 
reason  one  should  always  inquire,  in  buying  dressed  poultry,  how 
long  it  had  been  killed. 

id)  Young  Cockerels. — Must  be  scalded  before  picking.  Before 
roasting,  the  hair  must  be  singed  off,  and  they  must  be  carefully 
washed  and  rubbed  with  salt  inside  and  outside ;  afterward  they 
are  put  in  a  pot  with  plenty  of  hot  butter,  roasted  brown  on  both 
sides,  with  frequent  basting,  for  which  three-quarters  to  one  hour 
is  necessary.  The  sauce  is  made  as  above,  with  a  little  flour.  One 
hundred  gm.  of  raw  chicken  equal  100  calories. 

{b)  Capons  and  Pullets. — Should  be  roasted  with  little  butter, 
since  they  are  generally  fat  enough.  According  to  their  size  they 
must  be  roasted,  with  frequent  basting,  from  one  and  one-half  to 
two  hours. 

[c]  Young  pigeons  are  treated  just  as  young  cockerels.  Time 
of  roasting  about  three-quarters  of  an  hour. 

{d)  The  Pheasant. — Yields  a  fine  roast  after  it  has  hung  about 
eight  to  fourteen  days.  Roast  it  from  two  to  three  hours  with 
plenty  of  butter  and  frequent  basting. 

{e)  The  Partridge. — The  same  must  be  young  and  must  have 
been  killed  several  days  before  using,  in  order  to  furnish  a  tender 
roast.  After  it  has  been  picked,  cleaned,  and  washed,  it  is  put  in 
a  tolerable  quantity  of  hot  butter,  and  a  piece  of  fresh  butter  is 
also  put  inside  the  partridge.  On  the  other  hand,  wrapping  with 
bacon  is  less  to  be  recommended  for  those  having  stomach  trouble, 
and  a  roast  just  as  juicy  can  be  obtained  by  diligent  basting;  the 


26o  DIET    LISTS. 

palatability  can   also  be  increased  by  the   addition  of  white  wine 
and  sour  cream.     Time  of  roasting,  one  and  one-quarter  hours. 

(/)  Boiled  Cockerels  and  Pigeons. — They  are  prepared  just  as 
for  roasting,  then  laid  in  boiling,  slightly  salted  bouillon,  to  which 
a  little  julienne  has  been  added,  and  boil  one  to  one  and  one- 
quarter  hours.  Very  young  pigeons  are  cooked  soft  in  three- 
quarters  of  an  hour  ;   likewise  very  young  cockerels. 

14.  Roast  Game. 

{a)  Roast  Hare. — The  hare  is  skinned  and  then  cleaned,  but  the 
liver,  heart,  head,  etc.,  are  not  to  be  used  in  cooking  for  the  sick. 
After  the  roast  has  been  thoroughly  washed  within  and  without,  it 
is  well  salted,  and  larded  with  fresh  (not  smoked)  bacon,  and 
treated  exactly  as  the  roast  lamb,  so  that  it  is  done  in  about  one 
and  one-half  hours.  By  the  addition  of  sour  cream  the  roast  hare 
becomes  very  good,  but  in  this  way  it  does  not  agree  with  every 
one.  The  sauce  is  prepared  in  the  same  way  as  in  the  case  of  fillet 
roast,  with  flour  and  beef-tea. 

{6)  Roast  Venison  (Doe). — The  venison  saddle  is  the  most  bene- 
ficial game  for  those  who  have  stomach  troubles.  It  is  to  be  treated 
exactly  as  the  roast  hare,  only  it  must  be  roasted  about  two  and 
one-half  hours,  on  account  of  its  size.  The  joint  of  venison  will 
gain  considerably  in  tenderness  and  flavor  if  it  is  laid  in  light  red 
wine  a  few  days  before  using;  for  the  rest  it  is  to  be  treated  exactly 
as  the  venison  saddle,  only  it  must  be  roasted  two  and  one-half, 
three,  or  four  hours,  according  to  size.  The  sauce  is  the  same  as 
with  roast  hare.  But  game  can  also  be  treated  in  the  English  fashion, 
by  roasting  it  only  a  short  time,  as  in  the  case  of  fillet  and  roast 
beef  A  venison  joint  thus  requires  one  and  one-quarter  hours, 
approximately,  with  strong  heat,  and  if  very  heavy,  one  and  one- 
half  hours.  A  venison  saddle,  if  young  and  tender,  requires  three- 
quarters  of  an  hour  ;  if  older,  one  and  one-quarter  hours.  In  this 
way  the  meat  remains  juicier  and  stronger. 

{c)  Venison  Saddle  (Stag).— Is  to  be  treated  in  the  same  way, 
except  that  it  must  be  roasted  a  correspondingly  longer  time  ;  but 
generally  the  meat  is  not  as  tender  and  palatable  as  that  of  the  doe. 
One  hundred  gm.  of  game  (roast)  equal  about  215  calories  (when 
thoroughly  done). 

1 5 .  Stewed  Meats. 

{a)  Preserved  Veal. — The  meat  from  a  leg  or  breast  which  has 
hung  sufiiciently  is  cut  into  pieces  the  size  of  a  walnut ;  the  latter 


STEWED    MEATS.  26 1 

are  put  into  a  small  stewpan  with  hot  butter,  and  a  little  salt 
sprinkled  over  ;  immediately  after  they  have  been  once  turned  in 
the  butter,  j4  of  a.  glass  of  white  wine,  about  75  gm.,  is  poured  in 
and  the  whole  covered  up  well  and  stewed  for  one  and  a  quarter 
hours  with  moderate  heat,  some  good  bouillon  being  added  from 
time  to  time  ;  one  quarter  of  an  hour  before  serving,  the  sauce  is 
prepared  in  the  way  before  indicated,  and  immediately  before  serv- 
ing, the  yolk  of  an  egg  is  mixed  with  water  and  put  into  the  sauce. 

{d)  Preserved  Sweetbread. — The  sweetbread  is  cooked  till  it  is 
soft  as  in  the  case  of  soup,  is  skimmed,  cut  into  two  halves  and  ten 
minutes  before  serving  is  laid  in  butter  sauce,  to  be  prepared  in  the 
following  way :  A  little  piece  of  butter  is  melted  in  a  small  dish, 
without  being  allowed  to  brown  ;  then  one  tablespoonful  of  flour  is 
added,  well  mixed  with  the  butter;  then  pour  in  cold  bouillon  and 
a  little  white  wine,  so  that,  after  the  sauce  has  boiled,  the  whol-e 
forms  a  tolerably  thick  liquid.  The  amount  of  the  ingredients 
must  be  determined  by  the  amount  of  sauce  desired.  Before  serv- 
ing, the  yolk  of  an  egg  is  added  to  the  sauce. 

[c)  Stewed  Cockerels  or  Pigeons. — A  young  cockerel  or  pigeon 
is  dressed  as  for  roasting,  quartered  into  equal  parts,  slightly  salted, 
and  laid  in  a  stewpan  in  which  a  small  piece  of  butter  has  been 
previously  melted  without  being  browned.  The  stewpan  is  covered 
tightly  and  the  poultry  stewed  slowly  for  a  quarter  of  an  hour. 
Then  ^  of  a  glass  of  white  wine,  about  75  gm.,  and  some  good 
bouillon  are  added,  and  it  is  again  allowed  to  stew  for  about  three- 
quarters  of  an  hour  longer,  a  little  beef-tea  being  added  from  time 
to  time.  The  sauce  is  the  same  as  in  the  case  of  stewed  veal.  One 
hundred  gm.  of  meat  equal  about  120  calories. 

16.  Dislies  from  Chopped  Fresh  Meat. — Be  warned  against  allow- 
ing the  butcher  to  chop  the  meat,  as  in  some  cases  less  desirable  or 
less  appetizing  meat  may  be  mixed  in.  Every  household  should 
possess  a  machine  for  chopping  meats ;  in  cases  where  there  is 
none,  do  not  mind  the  trouble  of  chopping  it  yourself. 

{a)  Roast  Chopped  Meat. — One-half  of  a  pound  of  veal,  j4  of  a 
pound  of  beef,  and  ^  of  a  pound  of  pork,  not  entirely  lean,  are  put 
through  the  chopping  machine ;  the  whole  mass  is  then  mixed  in  a 
dish  with  three  whole  eggs,  ^^  of  a  liter  of  milk,  ij4  grated  rolls, 
and  a  tolerable  amount  of  salt ;  if  the  dough  then  seems  too  stiff,  a 
little  more  milk  may  be  added.  The  mass  is  made  into  a  longish 
cake   and   roasted  in  hot  lard  or  good  butter  (100  gm.)  first  on  one 


262  DIET    LISTS. 

side  and  then  on  the  other,  until  it  is  light  brown.  Time,  one 
hour  and  a  quarter.  From  this  hardly  any  sauce  will  be  obtained, 
hence  one  must  be  prepared  from  flour,  bouillon,  extract  of  meat, 
and  a  little  white  wine,  which  is  to  be  poured  over  a  quarter  of  an 
hour  before  serv^ing.  One  hundred  gm.  of  this  roast  equal  about 
250  calories. 

{d)  Cutlets  from  Chopped  Meat. — The  same  mixture  as  in  the 
preceding  is  made  into  little  cutlets,  allowed  to  fry  on  both  sides  in 
hot  butter  until  light  brown  ;  then  skim  off  all  fat,  prepare  a  butter 
sauce,  pour  it  over,  and  let  it  fry  with  this  for  another  half  hour. 

(c)  Meat  Balls  (Veal). — One  pound  of  meat  from  the  leg  is 
chopped  up  fine  in  the  machine ;  40  gm.  of  butter  are  stirred  to  foam, 
two  whole  eggs,  and  one  roll,  grated  fine,  are  added  ;  also  a  little  salt, 
and  according  to  taste  of  the  individual  a  little  finely  chopped  parsley. 
Of  this  mass  flat  cakes  are  made  and  cooked  for  one-quarter  of 
an  hour  in  salt  water;  butter  sauce,  or  when  allowed,  anchovy 
sauce,  is  added,  which  is  to  be  poured  over  the  cakes  one-quarter 
of  an  hour  before  serving.     One  hundred  gm.  equal  250  calories. 

17.  Dislics  from  CJiopped  Roast  Meat. 

[a)  Hash. — In  a  little  butter  or  lard  put  some  finely  chopped 
roast  meat  (veal,  fowl,  or  game),  stew  for  five  minutes  with  frequent 
stirring  and  pour  over  any  sauce  remaining  from  the  roast,  or  make 
a  special  sauce  as  follows:  Sprinkle  some  fine  flour  upon  the 
stewed  meat,  mix  well,  pour  in  a  little  w^hite  wine  and  enough 
bouillon  so  as  to  produce  a  rather  thick  gruel.  Then  stew  for  one- 
quarter  of  an  hour  longer  with  moderate  heat,  keeping  the  vessel 
w^ell  covered.  The  hash  is  now  done.  A  little  extract  of  meat 
added  will  improve  the  flavor.  One  hundred  gm.  equal  about 
225  calories. 

{]?)  Meat  Pudding. — Sixty  gm.  of  butter  are  stirred  until  foamy, 
four  yolks  of  eggs,  salt,  and  a  little  fine-cut  parsley  added.  Two 
French  rolls  are  grated  fine,  the  inside  cut  into  small  pieces,  and 
soaked  in  milk,  in  which  it  remains  one  hour;  170  gm.  of  roast  meat 
is  cut  fine  or  chopped  in  a  machine ;  the  grated  rolls  are  taken  out 
of  the  milk,  pressed,  and  with  the  chopped  roast  meat  mixed  with 
the  other  mass  (butter  and  eggs).  If  allowed,  two  tablespoonfuls  of 
sour  cream  may  also  be  added.  At  last  the  whipped  whites  of  four 
eggs  are  mixed  in,  and  the  whole  dough  is  put  in  a  mold  rubbed 
with  butter,  and  stewed  with  dust  from  the  rolls.  In  this  the  pud- 
ding is  cooked  for  one  and  one-quarter  hours  in  a  waterbath.    Any 


PREPARATION    OF   JELLIES.  263 

sauce  remaining  from  a   roast  is   added  (or  anchovy  sauce).     One 
hundred  gm.  equal  about  220  calories. 

(c)  Omelette  Souffle  from  Remnants  of  Roasts. — Forty  gm.  of 
finely  cut  roast  meat  are  mixed  with  one  tablespoonful  of  sweet  or 
sour  cream  ;  a  little  salt  and  the  yolk  of  an  egg  are  added  ;  the 
whipped  white  of  an  egg  is  mixed  in ;  the  mass  is  put  into  a  small 
porcelain  mold  and  baked  in  a  well-heated  oven  for  twenty  min- 
utes;  sauce  from  a  roast  is  added.  The  whole  mass  equals  215 
calories. 

(d)  Sweetbread  Pudding  (according  to  Hedwig  Hehl). — Twenty- 
five  gm.  of  French  rolls  are  grated  and  laid  in  milk.  The  sweet- 
bread is  cooked,  until  soft,  in  bouillon  or  salt  water,  skinned,  and 
cut  into  small  blocks.  Thirty  gm.  of  butter  are  stirred  until  foamy, 
and  two  yolks  of  eggs,  the  roll  which  has  been  pressed  out,  a  little 
salt,  parsley,  and  the  blocks  of  sweetbread  are  put  into  the  butter, 
with  which  the  whipped  white  of  an  egg  is  mixed  ;  the  whole  is 
put  into  a  cup  well  rubbed  with  butter,  covered,  and  cooked  for 
three-quarters  of  an  hour  in  the  waterbath.  Anchovy  sauce  or 
meat  gravy  is  added.     One  hundred  gm.  equal  about  150  calories. 

IV.  Jellies. 

I.  WieVs  Jelly,  for  Dyspeptics. — Take  off  the  skin  and  meat  from 
a  calf's  foot,  mash  the  bones,  and  put  on  the  stove  with  some  cold 
water  until  it  is  heated  to  foaming,  when  all  refuse  will  be  sepa- 
rated. After  rinsing  off  the  scum  with  cold  water,  put  the  bones 
with  y^  of  a  k.  of  beef,  or  ^  of  an  old  hen,  and  i  ^  liters  of  water, 
and  five  gm.  of  salt,  and  boil  slowly  from  four  to  five  hours.  Pour 
the  jelly  thus  formed  through  a  fine  sieve,  and  place  overnight  in 
the  cellar.  Next  morning  take  off  the  layer  of  fat,  and  to  clarify  the 
cold  jelly  add  one  egg  with  the  mashed  shell,  and  mix  with  steady 
beating  and  stirring.  Then  subject  the  whole  with  constant  beating 
and  stirring  to  a  temperature  of  not  over  60°  R.  (or  else  the  white 
of  the  egg  will  curdle).  If  the  jelly  begins  to  show  grains,  cover 
and  let  cool,  until  the  white  of  egg  becomes  flaky  and  separates 
itself  Hereupon  strain  a  few  times  more  until  it  becomes  perfectly 
clear,  add  five  gm.  of  extract  of  meat,  and  pour  the  jelly  into  a  mold 
and  let  cool  again.  An  addition  of  gravy  from  a  roast  is  very  pala- 
table. It  must  be  mixed  in  while  the  mass  is  still  warm  and  liquid. 
The  dish  is  very  palatable  with  cold  fowl,  but  does  not  keep  well 
in  summer,  and  had,  therefore,  best  be  put  on  ice. 


264  DIET    LISTS. 

2.  Ichtliyocol  Jelly. — Cut  15  gm.  of  ichthyocol  into  small  pieces 
and  let  soften  in  ^  of  a  liter  of  cold  water  for  eight  to  ten  hours ; 
boil  for  one-quarter  of  an  hour  and  add  gravy  from  a  roast  and 
extract  of  meat.  Pour  the  mass  when  hot  through  a  fine  cloth,  or, 
better,  through  filter-paper.  One  can  add  to  100  gm.  of  the  liquid 
also  0.5  gm.  of  hydrochloric  acid,  or  ten  gm.  of  white  wine. 

3.  Milk  Jelly. — Boil  two  liters  of  milk  for  five  to  ten  minutes  with 
250  gm.  of  sugar.  To  the  well-cooled  mixture  add,  while  slowly 
stirring,  a  solution  of  30  gm.  of  white  gelatin  in  250  gm.  of  water, 
and  also  add  three  wineglassfuls  (400  gm.)  of  good  Rhine  wine,  or 
30  gm.  of  cognac;  afterward  pour  the  mass  into  a  form  and  let 
cool.     One  hundred  gm.  equal  about  250  calories, 

V.  Vegetables. 

1.  Asparagus. — The  asparagus  stems  are  washed,  peeled  from  the 
top  downward,  and  the  lower  woody  ends  cut  off;  then  they  are 
bound  in  a  small  bundle,  and  cooked  until  soft  in  salt  water,  which 
requires,  according  to  the  thickness  of  the  stems,  one-half  to  one 
hour;  a  large  quantity  of  water  must  be  used  in  cooking,  otherwise 
the  asparagus  easily  takes  on  an  ugly  color.  Make  a  butter  sauce 
with  yolk  of  &^^.  Dyspeptics  can  take  only  the  soft  heads  without 
sauce.     One  hundred  gm.  equal  about  20  calories. 

2.  Spinach. — The  spinach  leaves  are  carefully  picked,  washed,  and 
laid  in  boiling  salt  water,  in  which  they  are  to  be  cooked  slowly, 
without  being  covered,  for  otherwise  they  lose  their  color  easily. 
After  twenty  minutes  put  them  on  a  sieve,  pour  cold  water  over  them 
and  press  them.  Then  cut  the  spinach  very  fine  or  pass  through  a 
hair  sieve,  lay  in  a  little  melted  butter,  dust  flour  over  it  several 
times,  and  add  strong  bouillon.  At  last,  mix  in  the  yolk  of  an 
egg  with  cold  bouillon.  One  hundred  gm.  equal  165  calories 
(prepared  from  250  gm.  of  spinach  leaves). 

3.  Conifrey  or  Briiisewort. — Wash,  clean  carefully,  cut  in  pieces 
two  inches  long,  and  also  split  the  thicker  pieces  lengthwise.  Mix 
one  tablespoonful  of  flour  with  one  liter  of  water  and  one  table- 
spoonful  of  vinegar,  and  lay  each  cleaned  piece  of  root  in  the 
mixture.  Afterward  they  are  again  rinsed  on  a  sieve  with  clean 
water,  laid  in  melted  butter,  salted,  covered  tightly  and  stewed, 
adding  strong  bouillon  from  time  to  time.  According  to  size  and 
age  the  roots  require  from  three-quarters  to  one  and  one-half  hours 
in  order  to  become  soft.    One  hundred  gm.  equal  about  120  calories. 


PREPARATION  OF  VEGETABLES.  265 

4.  Green  Peas. — The  peas  (i^)  are  hulled  and  stewed  in  15  gm. 
of  butter  and  bouillon  as  the  preceding  ;  time,  one  to  one  and  a  half 
hours.  Or,  take  canned  peas  and  put  the  opened  can  in  hot  water, 
or  cook  them  with  the  same  amount  of  butter  and  some  salt.  For 
the  sick  it  is  advisable  to  pass  the  peas  through  a  sieve  and  serve 
them  as  a  puree.  One-half  of  a  liter  of  peas  yield  280  gm.  of  pea 
puree;   of  this,  100  gm.  equal  160  calories. 

5.  Carrots. — Carrots  are  serviceable  in  the  dietetic  kitchen  only 
when  very  young  and  tender.  They  are  cleaned,  washed,  cut  into 
pieces  and  then  stewed  similarly  to  peas.  The  time  is  also  the  same. 
If  it  is  desired  to  serve  them  as  a  puree,  they  are  passed  through  a 
hair  sieve  after  they  are  cooked  ;  a  little  flour  dusted  over  them 
and  cooked  to  a  thick  mush.  One  hundred  gm.  of  puree  equal 
120  calories. 

6.  Beans  {Green^. — Young  beans  are  cleaned,  washed,  cut  fine, 
and,  like  the  peas,  stewed  in  butter  and  bouillon.  In  a  season 
when  there  are  no  young,  fresh  vegetables,  one  can  use  to  advan- 
tage canned  beans,  of  which  Prince  beans  (Flagiolettes)  are  the 
tenderest.     One  hundred  gm.  equal  about  40  calories. 

7.  Cauliflower. — The  cauliflower  is  cleaned,  washed,  and  treated 
like  the  asparagus.  Time  of  cooking,  one-half  hour.  One  hundred 
gm.  equal  about  60  calories. 

8.  Rice  in  Bouillon. — Thirty  gm.  of  rice  are  washed  twice  on  the 
previous  evening,  and  then  water  in  which  a  little  carbonate  of 
soda  has  been  dissolved  is  poured  over  it,  so  that  the  rice  may 
swell  during  the  night;  then  the  water  is  drained  off,  and  the  rice 
with  a  piece  of  butter  and  some  strong  bouillon  is  put  in  a  stew- 
pan  and  stewed  for  one  and  one-quarter  hours,  tightly  covered, 
except  the  last  quarter  of  an  hour  ;  finally  the  beaten-up  yolk  of 
an  egg  is  added.  Now  rinse  out  a  small  porcelain  dish  with  cold 
water,  without  drying  it,  and  press  the  rice  into  it,  let  stand  five 
minutes  and  then  turn  the  mold.  The  amount  is  calculated  for 
one  person,  and  is  best  suited  for  a  side  dish  to  meats.  The  whole 
equals  about  225  calories. 

9.  Chestnut  Puree. — One- half  kilo  of  chestnuts  are  peeled  and 
boiled  in  water  as  long  as  to  get  the  second  (inside)  skin  off  easily. 
The  chestnuts  are  laid  upon  a  sieve  until  all  the  water  has  drained 
off.  Then  they  are  mashed  in  a  dish  and  afterward  pressed 
through  a  hair  sieve.  One  hundred  gm.  of  butter  are  melted  in  a 
stewpan  on  the  fire  ;  a  little  salt  and  sugar,  enough  to  cover  the 

18 


266  DIETETIC    KITCHEN. 

point  of  a  knife,  are  added  (to  the  butter),  and  then  the  chestnuts 
are  put  in.     Stew  them,  with  frequent   stirring,  for   one-half  hour, 
and  pour  in  enough  bouillon  to  get  a  mush  not  too  thick. 
VI.   Side    Dishes   from   Eggs  and   Flour. 

1.  Scrambled  Eggs. — Two  eggs  are  thoroughly  beaten  with  a 
little  salt  until  yolk  and  white  are  completely  mixed.  Then  melt 
five  gm.  of  butter  in  a  small  enameled  vessel,  add  the  &^^  mixture, 
and  heat,  with  continued  stirring,  until  a  rather  thick  mush  is 
formed.  Serve  in  a  well-warmed  dish.  This  dish  is  suitable  with 
cold  roast,  ham,  smoked  meat,  etc.  Two  scrambled  eggs  equal 
about  200  calories. 

2.  Potato  Puree. — Peel  ^  of  a  pound  of  very  mealy  potatoes, 
cut  into  quarters,  wash,  and  cook  until  soft  in  a  steam-cooking 
apparatus ;  then  pass  through  a  coarse  hair  sieve ;  add  20  gm. 
of  fresh  butter,  a  little  salt,  and  60  to  70  gm.  of  warm  milk,  and 
beat  thoroughly  for  five  minutes  while  the  mixture  is  on  the  fire, 
until  it  becomes  very  foamy.  This  must  only  be  prepared  just 
before  serving,  as  it  loses  flavor  in  standing.  One  hundred  gm. 
equal  about  125  calories. 

3.  Suabian  Dinnplings. — One  hundred  gm.  of  flour,  two  eggs,  two 
tablespoonfuls  of  milk,  and  a  little  salt  are  thoroughly  stirred 
together;  the  dough  is  put  in  a  special  sieve  (coarse),  through 
which  it  is  forced  and  allowed  to  drop  into  strongly  salted 
boiling  water.  One  must  take  a  large  pot  with  plenty  of  water,  so 
that  the  dumplings  may  rise  better  ;  they  are  allowed  to  boil  for  half 
an  hour.  When  done  they  are  poured  on  a  large  sieve,  and  remain 
until  all  the  water  has  drained  off.  Meanwhile  melt  in  a  stewpan 
ten  gm.  of  fresh  butter,  put  the  dumplings  into  it,  shake  them 
around  well,  and  serve.  The  sieve  necessary  is  known  only  in  South 
Germany,  but  it  can  be  made  by  any  tinner,  for  it  is  like  an 
ordinary  strainer,  the  holes  having  a  diameter  of  one  cm.  (about 
I"  of  an  inch).     One  hundred  gm.  equal  175  calories. 

4.  Roll  Dumplings. — Rolls  from  the  day  before  are  grated  (that  is, 
the  crust),  the  inside  is  cut  into  slices  and  cold  milk  poured  over  until 
the  bread  is  thoroughly  soft,  for  which  at  least  an  hour  is  necessary. 
Meanwhile  stir  60  gm.  of  butter  for  one-quarter  of  an  hour,  and 
add  slowly  four  eggs  and  a  little  salt.  Then  squeeze  the  milk  out 
of  the  slices  and  stir  them  with  the  butter  and  eggs  until  finely 
divided.  In  order  to  test  whether  the  mass  be  of  the  right  con- 
sistency, make  a  lump  as  large  as  a  walnut  and  boil  in  salt  water. 


FLOUR,    MILK,    AND    EGG    DISHES.  26/ 

If  it  breaks,  a  little  dust  from  grated  rolls  must  be  added.  When 
the  dough  has  acquired  the  necessary  firmness,  make  dumplings 
the  size  of  an  apple  (about  seven  from  the  given  quantity  of 
materials).  After  they  have  boiled  well  for  one-quarter  of  an  hour 
in  salt  water,  take  them  out  with  a  sieve  spoon,  cut  in  half,  and 
serve.     One  hundred  gm.  equal  250  calories. 

5 .  Vermicelli  ( Water  Noodles  or  Vegetable  Noodles) . — Forthedough 
take  180  gm.  of  flour,  and  three  eggs,  which  are  to  be  mixed  with 
the  flour  in  a  dish  ;  then  put  the  dough  on  a  board,  and  knead  well 
with  the  hands  until  it  is  tender.  Then  form  it  in  the  shape  of  a 
long  sausage  and  cut  into  four  equal  parts.  First  take  one  part : 
knead  into  a  flat,  round  cake  ;  weigh  off,  in  addition,  20  gm.  of  flour ; 
dust  the  board  and  rolling-pin  with  this,  and  roll  out  thin  (20  gm. 
of  flour  will  suffice  for  all  the  four  parts  of  the  dough).  At  each 
turning  of  the  dough,  dust  the  board  again  with  flour,  so  that  the 
dough  may  not  stick  and  tear.  The  necessary  thinness  is  reached 
when  one  can  distinguish  through  the  dough  the  pattern  of  apiece 
of  calico,  etc.,  laid  underneath.  When  thin,  lay  the  four  parts 
on  a  clean  white  cloth  near  the  fire  ;  let  them  become  half  dry, 
and  cut  into  strips  one  cm.  broad,  which  are  to  be  separated  and 
hung  up  in  the  kitchen  to  dry  for  twelve  hours.  They  can  be  kept 
for  some  time  in  a  tureen.  When  using,  lay  them  for  ten  minutes 
in  boiling  salt  water;  pour  off  the  water  through  a  strainer,  and 
put  the  noodles  in  a  dish.  Vegetable  noodles  of  very  good  quality 
are  now  also  made  by  factories.  One  hundred  gm.  of  boiled  noodles 
equal  about  190  calories. 

6.  Macaroni. — Buy  only  the  best  quality.  Put  in  a  vessel  with 
much  boiling  water,  and  after  they  have  boiled  ten  minutes  pour 
off  the  water;  pour  over  some  more  boiling  salt  water  and  let  boil 
for  half  an  hour.  Drain,  put  in  a  stewpan  with  a  little  butter  (which 
is  on  the  fire),  mix,  and  serve  immediately.  One  hundred  gm. 
equal  about  150  calories.  One  can  also,  instead  of  putting  hot 
butter  over  the  macaroni,  add  a  butter  sauce,  described  under 
"  preserved  sweetbread."  When  the  macaroni  has  been  drained, 
put  in  a  porcelain  dish,  in  which  it  is  served,  pour  the  thickish 
sauce  over  and  put  the  dish  for  ten  minutes  in  the  oven. 

VII.    Flour,  Milk,  and  Egg  Dishes. 

I.  Rice  Mush. — Thirty  gm.  of  rice  (Caroline  rice  is  the  best)  is 
washed  the  night  before  twice,  thoroughly ;  then  cold  water,  in 
which  a  little  carbonate^of  soda  has  been  dissolved,  is  poured  over, 


268  DIETETIC    KITCHEX. 

and  allowed  to  stand  until  the  next  day.  Before  using,  the  water 
is  poured  off;  yi  of  a  liter  of  milk  is  boiled  and  the  rice  then  added 
and  boiled,  well  covered  up,  for  one  and  one-quarter*  hours  on  a 
moderate  fire,  with  frequent  shaking.  If  the  milk  becomes  too 
thick  from  boiling  before  the  rice  has  been  thoroughly  softened, 
add  a  little  more  hot  milk.  Whip  the  whites  of  two  eggs,  and  just 
before  serving  mix  lightly  with  the  rice ;  if  it  is  desired  to  make  it 
more  nourishing,  the  yolks  of  the  two  eggs  can  also  be  added 
before  the  whites  (this  quantity,  for  one  person,  equals  700  calories). 
One  hundred  gm.  equal  about  160  calories. 

2.  Tapioca. — Boil  ^  of  a  liter  of  milk;  mix  20  gm.  of  best  im- 
ported tapioca  and  boil  for  one-quarter  of  an  hour  longer,  with 
constant  stirring.  Further  procedure  same  as  with  rice  (in  the 
same  way  oat-meal  may  also  be  treated).  Value  in  calories  of 
above  quantity,  about  250. 

3.  White  Pot. — Moisten  in  a  small,  well-enameled  pan  65  gm.  of 
fine  sugar  with  one  tablespoonful  of  water,  and  burn  to  caramel 
sugar.  This  requires  great  care,  for  the  sugar  easily  becomes  too 
dark  and  then  takes  on  a  bitter  taste.  On  a  hot  stove,  not  over  an 
open  fire,  one  must  constantly  stir  the  sugar  with  a  tin  spoon  until 
it  gets  a  fine  brown  color.  During  this  process  heat  a  tin  form, 
such  as  are  usually  used  for  sweet  dishes,  jelly,  etc.,  and  pour  into 
it  the  sugar  as  soon  as  it  has  browned,  and  let  it  spread  on  all  sides 
until  the  surface  of  the  plate  is  covered.  Then  let  cool.  Now 
beat  up  three  whole  eggs  in  a  dish,  add  h^  of  a  liter  of  unboiled 
milk,  the  contents  of  a  package  of  vanilla,  or  ]^^  of  a  stick  of  vanilla 
boiled  in  milk,  powdered  sugar  to  taste,  mix  the  whole  thoroughly, 
and  pour  into  the  form  with  the  sugar,  which  is  now  cold.  Put  on 
a  waterbath,  cover,  and  boil  until  the  mass  has  amalgamated,  which 
can  be  tried  by  thrusting  in  a  teaspoon.  Take  out  the  form,  allow 
it  to  cool,  and  upset  on  a  plate.  This  is  a  pleasant,  cooling,  well- 
tasting  dish,  nourishing  as  well  as  easily  digestible.  One  hundred 
gm.  equal  about  30  calories. 

4.  Egg  Creme  {according  to  Mrs.  Dr.  Pariser). — For  this  one 
reckons,  for  one  person,  one  yolk  of  tgg,  two  tablespoonfuls  of 
beaten  cream  flavored  with  vanilla,  sugar  according  to  taste,  a  few 
drops  of  arrack  or  cognac.  The  yolk  of  e.gg  is  first  beaten  with 
sugar,  to  foam.  Then  the  whipped  cream  is  added  and  well  mixed 
in  ;  at  last  a  few  drops  of  arrack  or  cognac  are  added,  and  the 
whole  served  in  wineglasses. 


PREPARATION    OF    PUDDINGS.  269 

5.  Vanilla  Crhne  {according  to  Mrs.  Dr.  Hughes). — Stir  four  yolks 
of  eggs  to  foam,  with  ^  of  a  pound  of  fine  sugar ;  boil  ^^  of  a 
liter  of  milk  with  some  vanilla  and  add  immediately  to  the  eggs  ; 
mix  with  an  egg-beater  and  again  put  on  the  fire,  with  continual 
stirring.  '  Six  pieces  of  white  gelatin  are  dissolved  in  a  little  hot 
water  and  poured  into  the  mass  while  the  latter  is  still  on  the  fire. 
As  soon  as  it  is  risen,  take  quickly  from  the  fire,  pour  through  a 
strainer  and  nearly  allow  it  to  cool,  with  constant  stirring.  Then 
the  whipped  whites  of  four  eggs  are  added  and  the  mass  poured  into 
a  porcelain  dish  which  has  been  rinsed  with  cold  water ;  allow  it  to 
cool,  and  turn  over  just  before  using.  A  fruit  sauce  may  be  served 
with  the  creme. 

6.  Roll  Pudding. — Stir  30  gm.  of  butter  until  foamy,  add  yolks  of 
two  eggs,  with  one  tablespoonful  of  fine  sugar,  15  gm.  of  grapes,  15 
gm.  of  raisins,  and  20  gm.  of  finely  grated  almonds.  The  outsides 
of  two  French  rolls  are  grated  off,  the  insides  cut  in  pieces,  soaked 
one  hour  in  milk,  and  then  squeezed  thoroughly  and  mixed  with  the 
rest  of  the  mass.  Now  the  whole  is  thoroughly  mixed,  the  whipped 
whites  of  two  eggs  stirred  in,  and  the  dough  put  into  a  form  rubbed 
with  butter  and  dusted  with  roll  dust.  Either  bake  the  pudding 
for  three-quarters  of  an  hour  in  the  waterbath  or  bake  in  a  small 
porcelain  dish  for  one-half  of  an  hour  in  an  oven.  Add  vanilla  or 
wine  sauce.  If  necessary,  the  almonds,  raisins,  and  grapes  may  be 
omitted.     One  hundred  gm.  equal  about  250  calories. 

7.  Tapioca  Pudding. — Thirty-five  gm.  of  tapioca  are  cooked  for 
five  to  seven  minutes  with  ^^  of  a  liter  of  milk  until  it  turns  to  a 
thick  mush.  Meanwhile  stir  to  foam  25  gm.  of  butter  ;  add  yolks 
of  two  eggs  and  one  small  tablespoonful  of  fine  sugar,  and  stir 
this  mass  into  the  no  longer  hot,  but  still  warm,  mush.  After  rub- 
bing a  small  porcelain  form  with  butter,  whip  the  whites  of  two 
eggs,  add,  and  mix  with  the  mass.  Put  into  the  form  and  bake  the 
pudding  in  a  well-heated  oven  for  three-quarters  of  an  hour.  One 
hundred  gm.  equal  175  calories. 

8.  Flour  Mush  Pjidding. — Melt  20  gm.  of  butter  in  a  saucepan  ; 
mix  in  smoothly  50  gm.  of  flour  and  yi  ofa  liter  of  milk,  and  cook  the 
mush  until  it  separates  from  the  pan.  Then  let  cool  a  little,  and 
add  afterward  one  yolk  of  ^gg.  Now  stir  until  foamy  20  gm. 
of  butter,  to  which  add  yolks  of  two  eggs,  ij4  tablespoonfuls  of 
sugar  and  one  teaspoonful  of  arrack,  and  with  this  mass  mix  the 
cooked  mush ;  then  whip  the  whites  of  the  three  eggs,  mix  lightly 


270  DIETETIC    KITCHEN. 

with  the  mass,  fill  into  a  form  rubbed  with  butter  and  dusted  with 
roll  dust,  and  let  cook  for  one  hour  in  the  waterbath.  One  hundred 
gm.  equal  about  220  calories. 

9.  Rice  Pudding. — Thirty-five  gm.  of  finest  rice  is  soaked  the 
night  before,  as  in  the  case  of  rice  mush.  Heat  ^  of  a  liter  of  milk, 
add  the  rice;  cover  and  cook  slowly  until  entirely  soft;  stir  25  gm. 
of  butter  to  foam,  add  two  yolks  of  eggs  and  one  tablespoonful  of 
sugar.  When  the  rice  has  become  lukewarm,  mix  in  the  other 
mass  ;  whip  two  whites  of  eggs,  put  the  dough  in  a  porcelain  form 
rubbed  with  butter,  and  bake  in  an  oven  for  half  an  hour.  One 
hundred  gm.  equal  about  150  calories. 

10.  Biscuit  Pudding. — Five  yolks  of  eggs  are  stirred  for  half  an 
hour  with  ^  of  a  pound  of  fine  sugar  ;  then  add  a  small  table- 
spoonful  of  fine  flour  and  a  little  vanilla;  also  a  little  arrack  and 
five  whipped  whites  of  eggs.  Rub  a  pudding  form  with  butter 
and  dust  with  fine  roll  crumbs;  fill  in  the  mass  and  cook  for  one 
hour  in  the  waterbath.     One  hundred  gm.  equal  215  calories. 

1 1.  Noodle  Pudding. — Of  the  best  egg  noodles  (fine)  take  70  gm., 
crumble  to  pieces,  throw  into  ^  of  a  liter  of  boiling  milk,  and  boil 
for  half  an  hour.  Meanwhile  stir  50  gm.  of  butter  until  foamy,  add 
three  yolks  of  eggs  and  about  one  tablespoonful  of  fine  sugar,  and 
mix  this  mass  with  the  half-cooled  mush.  At  last  whip  the  whites 
of  three  eggs,  mix  with  the  rest,  put  the  whole  in  a  form  rubbed 
with  butter,  and  bake  the  pudding  for  one  hour  in  the  oven. 

12.  Omelette  Sojiffl'e. — Stir  the  yolk  of  an  ^%%,  with  one  table- 
spoonful of  fine  sugar,  for  a  quarter  of  an  hour;  add  on  the  point 
of  a  knife  a  little  of  the  finest  flour,  one  tablespoonful  of  arrack, 
and  the  whipped  whites  of  i^  eggs.  In  an  omelette  pan,  melt 
five  gm.  of  butter,  and  meanwhile  put  on  the  hearth  a  porcelain 
soup  plate,  which  must  fit  the  pan  exactly,  and  heat  the  plate  well. 
Then  put  the  dough  in  the  pan,  and  cover  this  immediately  with 
the  hot  plate.  Now  bake  the  omelette  with  a  moderate  fire  until 
the  surface  has  become  solid,  which  requires  four  to  five  minutes; 
then  turn  out  on  another  warmed  flat  plate  ;  then  fold  in  the  middle, 
strew  sugar  over,  and  serve  at  once.  The  whole,  about  240  calo- 
ries. 

13.  Souffle  Baked  in  the  Oven. — Stir  the  yolks  of  two  eggs,  with 
35  gm.  of  sugar,  for  a  quarter  of  an  hour  ;  add  on  the  point  of  a 
knife  a  little  fine  flour,  and  one  tablespoonful  of  arrack  and  the 
whipped  whites  of  two  eggs  ;  then   at  once  fill  the  dough  into  a 


MISCELLANEOUS    PREPARATIONS.  2/1 

porcelain  form   rubbed  with  butter,  and  bake  eight  to  ten  minutes 
in  the  oven.     The  whole,  about  370  calories. 

14.  Snowballs  in  Vanilla  Crhne. — One  liter  of  milk,  with  one 
tablespoonful  of  fine  sugar,  mixed,  is  used  in  the  cooking.  The 
whites  of  four  eggs,  with  one  tablespoonful  of  sugar,  are  whipped 
until  stiff.  Then  from  the  whipped  eggs  longish  lumps  are  cut  out 
with  a  tin  spoon  and  these  put  into  the  boiling  milk.  The  milk 
must  be  put  on  the  fire  in  a  large,  wide  can  so  that  the  snowballs 
may  expand.  One  must  never  put  more  than  six  in  the  pan  at 
one  time.  When  they  have  lain  one  minute  in  the  milk,  turn  them  ; 
let  them  lie  another  minute  on  the  other  side,  take  them  out  care- 
fully, and  lay  on  a  large  platter.  After  the  whole  has  thus  been 
treated,  take  the  four  yolks  of  eggs,  mix  with  a  teaspoonful  of  fine 
flour,  i^  of  a  liter  of  milk,  and  a  package  of  vanilla,  and  make  of 
them  a  creme.  When  this  begins  to  boil  take  it  from  the  fire  ;  let 
it  cool,  and  just  before  serving  place  the  snowballs  upon  the  crhne 
in  a  porcelain  dish. 

VIII.  Miscellaneous. 

1.  Slewed  Apples. — Peel  good  apples,  cut  them  and  stew  with  a 
little  water  and  sugar  according  to  taste ;  then  pass  through  a 
coarse  hair  sieve.     One  hundred  gm.  equal  about  75  calories. 

2.  Pears. — Peel  good  pears,  cut  in  halves,  but  do  not  take  out 
seeds,  put  on  the  fire  with  plenty  of  water  and  a  little  sugar,  and 
boil  until  soft ;  a  little  wine  added  will  improve  the  palatability. 

3.  Wine  Sauce  or  Chandeaii. — Two  yolks  of  eggs  are  beaten  up 
in  a  small  pan,  with  i^  of  a  teaspoonful  of  the  finest  potato 
flour;  then  slowly  stir  in  ^  of  a  liter  of  good  wine  and  add  two  to 
three  tablespoonfuls  of  fine  sugar.  Put  on  the  fire  and  stir  until 
the  sauce  has  gained  a  thick  consistency ;  then  immediately  take 
from  the  fire  and  cover  ;  now  whip  two  whites  of  eggs,  and  pour 
the  sauce  into  this  slowly,  with  vigorous  stirring,  and  serve  at 
once.  Reckoning  the  value  in  calories  of  the  alcohol,  100  gm. 
equal  about  no  calories. 

4.  Vanilla  Sauce. — Mix  two  yolks  of  eggs  with  one  table- 
spoonful of  fine  sugar,  add  ^  of  a  liter  of  cold  milk,  a  little  vanilla 
or  )^  of  a  package  of  vanillin.  The  sauce  is  put  on  the  fire  and 
stirred  until  it  begins  to  thicken.  Then  take  from  the  fire  im- 
mediately and  serve.     One  hundred  gm.  equal  about  125  calories. 

5.  Aleuronat   Bread  [according    to  Dr.  Hiith,  Aerztl.   Centralbl., 


2/2  DIETETIC    KITCHEN. 

August,  1894,  No.  46). — Mix  500  gm.  of  aleuronat  flour  and 
1500  gm.  of  rye  flour;  mix  one-half  of  this  mass  with  one  liter 
of  warm  water,  two  good  tablespoonfuls  of  salt,  and  180  gm. 
of  yeast  finely  divided  in  a  little  water;  set  this  dough, 
sprinkled  with  a  little  flour,  to  rise.  After  the  usual  rise,  the 
dough  is  worked  up  with  the  remaining  flour  into  two  loaves. 
These  are  baked  in  square  pans  (10,  15,  20  cm.)  rubbed  with 
butter  ;  after  letting  them  rise  well  once  more,  they  are  baked  for 
two  hours  with  strong  heat. 
6.  Nutritive  Enemata  : 

(a)  Meat  Pancreas  Clyster  (according  to  Leube). — One  hundred 
and  fifty  gm.  of  good  beef  are  scraped  and  then  chopped  fine  ;  50 
gm.  of  fresh  pancreatic  gland,  free  from  fat  (either  of  a  cow  or  of  a 
hog),  are  mixed  with  this  and  stirred  carefully,  with  the  addition  of 
not  more  than  1 50  gm.  of  lukewarm  water.  Injections  of  from  50  to 
not  more  than  100  gm.  at  a  time  in  a  lukewarm  state,  by  means 
of  a  simple  funnel,  ending  in  a  nozzle  which  must  have  a  wide 
opening.  The  mixture  will  keep  only  a  short  while.  One  hundred 
gm.  equal  about  120  calories. 

[b)  Nutritive  Enema  (according  to  Ewald). — Two  or  three 
eggs  are  beaten  smooth  with  one  tablespoonful  of  cold  water 
and  a  little  salt,  as  much  as  can  be  held  on  the  point  of  a  knife. 
Wheaten  starch,  as  much  as  can  be  held  on  the  point  of  a  knife,  is 
boiled  with  ^  of  a  cup  (100  gm.)  of  a  20  per  cent,  solution  of 
grape  sugar,  and  one  wineglass  (150  gm.)  of  red  wine  added. 
Then  the  solution  is  cooled  to  30°  R.,  and  the  eggs  are  stirred 
in  slowly.  One  can  add  also  one  teaspoonful  of  meat  peptone, 
but  this  is  not  absolutely  necessary.  Nutritive  clysters  are  to  be 
injected  while  at  blood  heat,  and  in  quantities  of  250  gm.  at  a 
time.  Previously  the  rectum  must  have  been  cleansed  by  a 
purgative  clyster.  The  addition  of  grape  sugar  had  better  be 
omitted,  since  through  it  decomposition  and  irritations  of  the 
intestines   arise  (Wegele).     It  contains  about  400  calories.* 

{c)  Nutritive  Clyster  (according  to  Boas). — Warm  250  gm.  of 
milk,  and  stir  with  two  yolks  of  eggs,  one  teaspoonful  of  common 


*  In  calculating  the  value  in  calories  of  the  nutritive  clysters  it  is  to  be  noted  that 
the  amount  of  resorption  is  difficult  to  determine,  since  it  depends  upon  the  state  of 
the  intestines,  the  skill  of  the  patient  in  retaining  the  enema,  etc.  It  is  therefore  well 
to  assume  only  one-half  as  resorbed. 


MISCELLANEOUS    PREPARATIONS.  2/3 

salt,  and  one  tablespoonful  of  wheaten  starch,  and  afterward  add  one 
tablespoonful  of  red  wine.  If  the  mucous  membrane  of  the  rectum 
is  easily  irritated  one  may  add  four  to  five  drops  of  tincture  of 
opium.  Such  clysters  maybe  administered  from  one  to  four  times 
in  twenty-four  hours  (heated  to  blood  heat),  with  a  long-,  soft,  rectal 
tube  and  a  Heger's  funnel  and  tubing.  Contains  about  400 
calories. 

id')  Meat  Bouillon-wine  Clyster  (according  to  Fleiner). — Con- 
sists of  80  gm.  of  beef-tea  and  40  gm.  of  mild  white  wine  ;  to  be 
injected  two  or  three  times  a  day  at  body  heat.  (According  to 
Fleiner,  they  bring  sleep  to  weakened  patients.) 

7.  Alcoholic  Pancreas  Extract  (according  to  Dr.  Reichniart.) — A 
fresh  ox  pancreas  is  freed  from  fat  and  skin  immediately  after  kill- 
ing, chopped  up,  and  3^  of  a  liter  of  12  to  15  per  cent,  alcohol  is 
poured  over.  Let  stand  two  to  three  days  in  a  cool  place,  and 
filter.     One -wineglass  for  each  meal. 

The  following  is  a  meat  food  recommended  in  the  absence  of 
secretion  of  hydrochloric  acid  : 

Meat  Dumplings  zvith  Sardelle  Dressing  {according  to  Mrs.  Dr.  J. 
C.  Heinrneter\ — Take  ^  of  a  cup  of  finely  scraped  beef,  ^  of  a  cup  of 
lean  pork  ground  through  the  meat-chopper.  Add  salt  and  a 
small  amount  of  nutmeg  ;  2]/^  ounces  of  butter  creamed,  yolks  of  two 
eggs  creamed;  two  ounces  of  stale  bread  soaked  in  cold  water; 
after  it  is  softened  press  it  dry  and  add  to  the  meat ;  then  add  the 
beaten  white  of  one  egg  and  mix  all  thoroughly.  Turn  into  30 
dumplings  and  boil  for  five  minutes. 

Dressing. — Take  one  cup  of  beef  bouillon,  add  four  sardelles 
scraped  fine,  the  juice  of  ^  of  a  lemon,  and  boil  this  for  ten  minutes. 
Thereafter  add  j4  o(  a  glass  of  white  wine,  one  teaspoonful  of  corn- 
starch, lastly  the  yolks  of  two  eggs  stirred  in  a  little  water  ;  then 
strain  and  pour  over  the  dumplings.  Serve  only  in  a  covered 
tureen. 

Gelatin  Cream  {according  to  Mrs.  Dr.  J.  C.  Hemmeter)  for  Anacidtty 
Witho2/t  Symptoms  of  Stagnation. — Juice  of  two  oranges  and  one 
lemon,  slight  flavor  of  vanilla  extract,  j^  o(  a  pound  of  sugar; 
stir  well  and  then  add  one  pint  of  cream  and  beat  until  thick. 
Dissolve  ^  of  a  box  of  gelatin  in  i^  of  a  pint  of  cold  water;  heat 
very  gradually  until  all  is  thin  and  dissolved,  but  not  to  solidity. 
When  cool  add  the  cream,  and  beat  until  it  is  stiff.  Can  be  poured 
into  a  mold  and  given  any  shape. 


CHAPTER  III. 

THE  DIETETICS  OF  ALCOHOL  AND  ALCOHOLIC 
BEVERAGES. 

The  literature  on  the  subject  of  the  physiological  action  and  the 
metabolic  and  dietetic  influences  of  alcohol  is  very  extensive ;  its 
abnormal  growth  appears  to  those  who  make  an  effort  to  keep 
abreast  of  the  progress  and  advancement  of  experimental  therapeu- 
tics, out  of  all  proportion  to  any  real  increase  in  our  knowledge  of 
the  subject.  We  are  directly  concerned  only  with  the  (i)  value  (if 
any)  of  alcohol  as  a  food;  (2)  as  a  tonic  and  stimulant;  (3)  its  effects 
upon  the  digestive  functions.  The  use  of  alcohol  in  any  shape  is 
wholly  unnecessary  for  the  use  of  the  human  organism  in  health. 
A  large  number  of  persons  are  undoubtedly  wiser  and  prolong 
their  lives  by  total  abstinence.  This  may,  of  course,  with  certain 
limitations,  be  said  of  all  food  and  drink;  but  of  alcohol  it  should  be 
published  with  emphasis,  since  there  are  so  many  who  imagine  it 
is  indispensable,  when  in  reality  they  are  injured  by  it.  The  effects 
of  alcohol  on  other  organs  than  the  stomach  are  very  important ; 
but  we  must  refer  to  the  literature  on  the  special  experiments  :  For 
the  influence  of  C2H6O  on  the  heart  see  J.  C.  Hemmeter,  "  The 
Comparative  Physiological  Effects  of  the  Ethylic  Alcohol  Series  on 
the  Isolated  Mammalian  Heart"  (in  "  Studies  from  the  Biological 
Laboratory  of  the  Johns  Hopkins  University,"  vol.  iv.  No.  5).  On  the 
value  of  alcohol  on  various  body  functions,  see  Oilman  Thompson, 
"  Dietetics,"  pages  205  to  232;  Binz,  "  Pharmakologie  "  ;  Schmiede- 
berg,  "  Arzneimittellehre."  The  literature  on  the  effect  of  alcohol 
on  the  functions  of  the  stomach  can  be  found  in  the  text-books  of 
Riegel,  Boas,  Ewald,  Wegele,  Penzoldt  (vol.  iv  of  "  Handbuch  d. 
Therapie"),  Munk,  and  Uffelmann.  The  literature  is  too  great  and 
the  results  are  too  uncertain  to  permit  any  resume  to  be  given  here. 
The  question  arises,  "  Why  do  we  give  alcohol  in  gastric  therapeu- 
tics ?  Is  it  a  food  or  merely  a  stimulant?  In  doses  taken  ordinarily 
with  the  more  common  beverages  does  it  facilitate  or  retard  diges- 
tion ?  "     Most  of  the  text-books  mentioned  take  the  stand  that  as 

274 


THE    INFLUENXE    OF    ALCOHOL    ON    GASTRIC    DIGESTION.  2/5 

alcohol  is  oxidized  in  the  body  it  furnishes  a  considerable  amount 
of  energy. 

The  question  whether  alcohol  is  a  true  food-stuff,  capable  of  serv- 
ing as  a  direct  source  of  energy  and  of  replacing  a  corresponding 
amount  of  fats  or  of  carbohydrates  in  the  daily  diet,  is  a  matter  of 
controversy,  ^eich^ri  [Therapeutic  Gazette,  Feb.  15,  1890)  concludes 
that  moderate  doses  of  alcohol  do  not  affect  the  total  amount  of 
heat  produced  in  the  body  of  a  dog.  As  it  is  nearly  completely 
oxidized  in  the  body,  and  gives  off  considerable  heat  in  the  process, 
the  fact  that  the  total  heat  production  remains  unaltered  indicates 
that  the  oxidation  of  alcohol  protects  an  isodynamic  amount  of 
food-materials  in  the  body  from  consumption,  thus  acting  as  a  food- 
stuff capable  of  replacing  other  elements  of  the  food.  Opposed 
diametrically  to  these  results  are  those  of  Miura  {Zeitschr.  f.  klin. 
Medicin,  1892,  vol.  xx,  p.  137),  whose  observations  were  made  on 
his  own  metabolism,  after  he  had  brought  himself  into  a  condition 
of  nitrogen  equilibrium  upon  a  mixed  diet.  Then  for  a  time  a  por- 
tion of  the  carbohydrates  was  omitted,  and  its  place  substituted  by 
an  isodynamic  amount  of  alcohol.  The  result  was  a  loss  of  proteid 
from  the  body,  proving  that  the  alcohol  had  not  protected  the 
proteid  tissue  as  it  should  have  done  if  it  acts  as  a  food.  In  a 
third  period  the  old  diet  was  resumed,  and  after  nitrogen  equi- 
librium had  again  been  established,  the  same  proportion  of  carbo- 
hydrates was  omitted  from  the  diet, but  alcohol  was  not  substituted. 

When  the  diet  was  poor  in  proteid,  it  was  found  that  less  proteid 
was  lost  from  the  body  when  alcohol  was  omitted  than  when  it  was 
used,  indicating  that  so  far  from  protecting  the  tissues  of  the  body 
by  its  oxidation,  the  alcohol  exercised  a  directly  injurious  effect 
upon  proteid  consumption.  In  our  opinion,  the  effect  of  moderate 
quantities  of  alcohol  upon  metabolism  is  not  yet  satisfactorily  un- 
derstood, and  positive  statements  can  not  be  made  until  reliable 
experimental  results. have  accumulated. 

Concerning  the  effects  of  moderate  amounts  of  alcohol  on  diges- 
tion by  pepsin-hydrochloric  acid,  and  on  salivary  and  pancreatic 
digestion,  we  believe  the  following  abstract  of  Chittenden's  experi- 
ments [Ainerican  Journal  of  Medical  Sciences,  Jan.  to  April,  1896) 
to  be  a  clear  representation  of  this  matter. 

A  careful  study  of  Chittenden  and  Mendel's  results  (Chittenden 
and  Mendel's  paper  upon  "  The  Influence  of  Alcohol  upon  the 
Chemical    Processes  of   Digestion  ")    makes  it  evident :  That  we 


2/6  DIETETICS    OF    ALCOHOLIC    BEVERAGES. 

can  not  define  with  mathematical  exactness  the  action  of  a  given 
percentage  of  absolute  alcohol  on  pepsin  proteolysis,  since  varia- 
tion in  the  attendant  conditions,  i.  c\,  the  relative  amounts  of  pep- 
sin, acid,  and  proteid,  together  with  the  period  of  digestion,  the 
digestibility  of  the  particular  proteid,  etc.,  are  prone  to  modify  the 
final  result.  Thus,  with  a  weak  gastric  juice,  where  the  amount  of 
ferment  present  is  small,  and  digestive  action  consequently  slow, 
or  where  the  proteid  material  used  is  difficult  of  digestion,  the 
retarding  effect  of  a  given  percentage  of  alcohol  is  far  greater  than 
when  the  digestive  fluid  is  more  active  ;  that  is,  when  it  contains 
more  pepsin.  Further,  this  difference  of  action  is  more  pronounced 
the  larger  the  percentage  of  alcohol  present.  The  following  gen- 
eral conclusions  were  drawn  from  artificial  digestive  mixtures. 

Fh'st.  It  is  plainly  manifest  that  in  the  presence  of  small  amounts 
of  alcohol  (one  to  two  per  cent,  of  absolute  alcohol),  gastric  diges- 
tion may  proceed  as  well  or  even  better  than  under  normal  circum- 
stances. In  fact,  many  of  their  experiments  show  a  slight  increase 
in  digestive  power  when  the  mixture  contained  one  or  two  per  cent, 
of  absolute  alcohol.  This  increased  digestive  action, though  slight, 
occurred  too  frequently  to  be  the  result  of  mere  accident,  and  appa- 
rently indicates  a  tendency  for  alcohol,  when  present  in  small  quan- 
tity, to  increase  slightly  the  digestive  action  of  pepsin-hydrochloric 
acid ;  or,  in  other  words,  to  stimulate  the  ferment  so  that  it  can 
accomplish  somewhat  more,  under  given  conditions,  than  it  other- 
wise could  do.  As  the  percentage  of  alcohol  is  raised,  retardation 
or  inhibition  becomes  more  noticeable,  although  ordinarily  it  is  not 
very  pronounced  until  the  digestive  mixture  contains  five  to  ten 
per  cent,  or  more  of  absolute  alcohol.  With  15  to  18  per  cent,  of 
absolute  alcohol  digestive  action  may  be  reduced  one-quarter,  or 
even  one-third;  the  exact  amount  of  retardation,  however,  being 
especially  dependent  upon  the  strength  or  activity  of  the  gastric 
juice  and  upon  the  natural  digestibility  of  the. proteid  material.  It 
is  to  be  remembered,  however,  that  18  per  cent,  of  absolute  alcohol 
would  be  equivalent  to  36  per  cent,  of  proof-spirit,  so  that  if  we 
could  assume  the  contents  of  the  human  stomach  at  a  given  period 
to  be  one-third  proof-spirit,  it  might  perhaps  be  considered  that 
digestive  action  would  be  retarded  to  the  extent  of  25  to  35  per 
cent.,  provided  the  gastric  juice  present  in  the  stomach  was  of 
fair  strength  and  the  proteid  matter  of  ordinary  digestibility. 
Such  percentages   of  proof-spirit,  however,   are   not   likely  to  be 


EFFECT    OF    ALCOHOL    ON    PROTEOLYSIS.  2'J'J 

long  present  in  the  stomach,  and  it  is  perhaps  idle  to  speculate  on 
such  hypothetical  cases.  We  may  in  this  connection,  however, 
again  emphasize  the  fact  that  the  stronger  the  gastric  juice,  and  the 
more  digestible  the  proteid  food  undergoing  digestion,  the  less 
retardation  will  a  given  percentage  of  alcohol  produce  ;  while,  on  the 
other  hand,  the  weaker  the  gastric  juice  and  the  more  indigestible 
the  proteid,  the  greater  will  be  the  inhibition  caused  by  a  given  per- 
centage of  alcohol.  In  other  words,  those  variations  which  must 
naturally  exist  in  the  stomach  contents  of  different  individuals, 
both  in  health  and  disease,  will  lead  to  different  degrees  of  retarda- 
tion in  the  presence  of  given  percentages  of  absolute  alcohol.  It 
would,  therefore,  be  unwise  to  make  a  general  specific  statement 
regarding  the  action  of  a  given  percentage  of  alcohol.  Under 
definite  conditions,  however,  as  Chittenden's  experiments  plainly 
show,  the  presence  of  a  definite  amount  of  alcohol  always  leads  to 
essentially  the  same  results. 

In  order  to  prevent  any  misinterpretation  of  these  results,  we 
would  again  call  attention  to  the  fact  that  we  are  dealing  here  with 
only  one  of  the  four  questions  that  need  to  be  answered  before  we 
can  hope  to  fully  understand  the  influence  of  alcohol  on  gastric 
digestion  as  a  whole.  Thus,  the  results  afford  plain  evidence  of 
the  influence  of  alcohol  on  the  digestive  or  solvent  power  of  the 
gastric  juice  ;  but  we  should  not  be  justified  in  arguing  that  exactly 
the  same  results  would  follow  from  the  introduction  of  alcohol  into 
the  living  stomach.  The  action  of  a  given  percentage  of  alcohol 
on  proteolysis  alone  would  be  essentially  the  same  in  the  stomach 
as  in  a  beaker,  provided  the  alcohol  was  not  absorbed  into  the 
blood  and  thus  removed  from  contact  with  the  digestive  mixture, 
and  provided  it  did  not  exert  any  influence  on  the  character  of  the 
gastric  juice  secreted.  But  it  is  easily  conceivable  that  a  percent- 
age of  alcohol  which  does  not  interfere  with  solution  of  the  proteid 
food-stuffs  may  so  modify  the  amount  or  character  of  the  secretion 
that  digestion  might  be  greatly  stimulated  or  greatly  retarded. 
Further,  as  already  stated,  the  presence  of  alcohol  in  the  stomach 
may  so  affect  absorption  and  peristalsis  that  the  rate  of  digestion 
maybe  modified  from  this  cause;  hence,  the  results  above  re- 
corded are  to  be  used  only  in  drawing  conclusions  as  to  the  effect 
of  various  percentages  of  alcohol  on  the  purely  chemical  process 
of  gastric  digestion,  i.  e.,  on  pepsin-proteolysis. 

In  conclusion,  it  is  to  be  noted  that  Chittenden's  results  are  more 


2/8  DIETETICS    OF   ALCOHOLIC    BEVERAGES. 

or  less  in  accord  with  what  has  been  previously  published  concern- 
ing the  action  of  alcohol  on  gastric  digestion.  Thus,  Bikfalvi 
found,  in  artificial  digestive  experiments,  that  alcohol,  even  in 
small  quantities,  retards  normal  gastric  digestion.  Klikowicz 
found  that  the  presence  of  five  per  cent,  of  alcohol  in  the  digestion 
of  egg-  and  serum-albumin  led  to  somewhat  variable  results, 
although,  as  a  rule,  there  was  an  indication  of  a  slight  stimulation 
of  proteolytic  action.  In  the  presence  of  ten  per  cent,  of  alcohol 
there  was  always  marked  retardation,  while  15,  20,  and  30  per  cent, 
of  alcohol  checked  digestion  to  a  marked  degree. 

Roberts  found  by  artificial-digestion  experiments  that  in  the 
presence  of  less  than  ten  per  cent,  of  proof-spirit  there  was  no 
appreciable  retardation.  With  ten  per  cent.,  retardation  was  only 
barely  detectable.  With  20  per  cent,  there  was  quite  distinct,  but 
still  only  a  slight,  retardation.  Above  this  point,  however,  the 
inhibitory  effect  of  alcohol  increased  rapidly.  (Refer  to  the  tables 
of  Roberts  at  the  end  of  this  chapter.)  That  the  action  of  a 
digestive  ferment  may  be  both  stimulated  and  retarded  by  the  same 
substance,  according  to  the  quantity  present,  has  been  already 
demonstrated  ;  hence  there  is  no  inconsistency  in  the  above  results 
with  alcohol.  The  same  action  has  likewise  been  observed  with 
yeast-cells. 

Action  of  Alcohol  on  Pancreatic  Digestion. — In  view  of  the 
position  which  pancreatic  digestion  occupies  in  the  digestive  pro- 
cess, it  is  readily  seen  that  it  is  more  desirable  to  ascertain  the 
influence  of  small  quantities  of  alcoholic  liquors  than  large 
amounts;  since  absorption  must  naturally  lead  to  a  decided 
diminution  of  alcohol,  etc.,  before  these  fluids  can  normally  become 
mixed  with  the  pancreatic  juice  and  partially  digested  food-material 
in  the  small  intestine.  Hence,  more  stress  was,  as  a  rule,  laid  upon 
the  influence  of  small  percentages  of  the  various  fluids  experi- 
mented with,  and  only  occasionally  the  action  of  large  quantities 
was  tried. 

The  results  with  absolute  alcohol  indicate  that  the  proteolytic 
ferment  of  the  pancreatic  juice  is  more  sensitive  to  absolute  alco- 
hol than  the  ferment  of  the  gastric  juice.  Retardation  of  diges- 
tive action  is  more  pronounced,  even  with  small  amounts  of  alco- 
hol. Further,  as  in  the  case  with  pepsin,  the  weaker  the  digestive 
powers  of  the  pancreatic  juice,  the  greater  the  retarding  action  of 
absolute  alcohol.     When  the   amount   of  alcohol   present   in  the 


ACTION    OF   ALCOHOL    ON    SALIVARY    DIGESTION.  2/9 

digesting  mixture  is  less  than  one  per  cent.,  the  retardation  of  the 
digestive  action  is  very  slight,  provided  the  ferment  is  fairly  vigor- 
ous in  its  action. 

Action  of  Alcohol  on  Salivary  Digestion. — [Methods  Em- 
ployed).— In  the  first  set  of  experiments  on  salivary  digestion 
Chittenden  determined  the  time  it  took  to  reach  the  achromic 
point.  By  this  method  he  found  it  to  be  manifest  that  absolute 
alcohol  has  very  little  influence  upon  the  amylolytic  or  starch- 
digesting  power  of  neutral  saliva.  Only  when  the  saliva,  added  to 
the  digestive  mixture,  is  diluted  in  the  proportion  of  i  :  30,  does 
the  presence  of  even  ten  per  cent,  of  alcohol  have  any  measurable 
influence,  and  then  only  to  retard  the  appearance  of  the  achromic 
point  two  minutes.  As  this  percentage  of  absolute  alcohol  is 
equal  to  at  least  20  per  cent,  of  proof-spirit,  it  follows  that  pure 
alcohol,  free  from  admixture,  is  practically  without  influence  upon 
the  digestion  of  farinaceous  food  by  the  saliva. 

By  the  second  method,  which  was  to  determine  the  amount  of 
maltose  formed,  he  found  that  small  amounts  of  absolute  alcohol 
may  actually  cause  an  increased  form^ation  of  maltose.  On  the 
other  hand,  the  presence  of  10  or  15  per  cent,  of  absolute  alcohol 
leads  to  a  distinct  retardation  in  the  formation  of  sugar,  although 
the  inhibition  is  not  very  pronounced  considering  the  amount  of 
alcohol  present.  This  retardation  of  the  secondary  action  of  the 
ferment  is  perhaps  suggested  by  the  slight  delay  in  the  appearance 
of  the  achromic  point  in  the  presence  of  ten  per  cent,  of  absolute 
alcohol. 

Concerning  the  effect  of  alcohol  on  the  gastric  motility,  we 
have  personally  made  a  number  of  observations  on  three  healthy 
students  with  normal  stomachs  by  means  of  our  method  of 
graphically  registering  the  gastric  peristalsis  on  the  kymographion 
{Neiv  York  Medical  Journal,  June  22,  1895).  These  students  were 
teetotalers,  and  to  exclude  the  influence  of  suggestion  the  alcohol 
was  poured  into  the  stomach,  diluted,  through  a  tube,  and  some- 
times water  was  used  in  place  of  alcohol.  The  subject  was  at  no 
time  aware  of  what  was  being  used.  It  was  found  that  alcohol, 
when  contained  in  gastric  contents  up  to  six  per  cent.,  exerts  no 
appreciable  effect  on  the  motility  one  way  or  the  other ;  but 
beyond  this  the  peristalsis  begins  to  be  interfered  with. 

The  presence  of  20  to  25  per  cent,  of  alcohol  leads  to  a  very 
distinct  retardation    and   reduction  of  the  tonicity  in  the  gastric 


28o  .        DIETETICS    OF    ALCOHOLIC    BEVERAGES. 

movements,  which  seems  to  last  in  its  effects  from  two  to  three 
hours.  Even  after  the  alcohol  is  thoroughly  washed  out  of  the 
stomach  the  peristalsis  continues  to  show  itself  embarrassed  if  the 
amounts  mentioned  have  been  used. 

In  dogs  the  identical  results  were  obtained,  except  that  at  five  to 
six  per  cent,  a  short  period  of  peristaltic  unrest  is  noticed  before 
the  marked  inhibition  develops.  The  inhibition  of  the  peristalsis 
when  the  gastric  contents  contain  20  to  25  per  cent,  of  alcohol 
occurs  quite  regularly,  and  is  not  the  result  of  mere  accident. 
It  is  probably  due  to  a  direct  poisoning  effect  on  the  muscularis, 
similar  to  the  poisoning  effect  on  the  heart  muscle  observed  by 
us  (Hemmeter,  "  Studies  from  the  Biological  Laboratory,"  loc.  cit). 
This  amount  of  alcohol  must  be  in  the  organ  at  least  ten  minutes 
before  the  peristaltic  inhibition  sets  in. 

The  effect  of  alcohol  on  the  rate  of  absorption  from  the  stomach 
is  a  different  question  from  the  absorbability  of  the  substance  itself. 
There  is  a  general  unanimity  that,  owing  to  its  rapid  diffusibility, 
alcohol  is  promptly  absorbed  from  mucous  surfaces.  At  the  same 
time  the  experiments  of  von  Mehring  suggest  that  the  absorption 
of  substances  soluble  in  alcohol  may  be  facilitated  by  the  latter  ; 
for  example,  that  peptone  or  maltose  taken  in  alcohol  may  be 
absorbed  more  rapidly  than  when  taken  in  water.  Exact  experi- 
mental facts  concerning  this  matter  are  wanting. 

In  large  doses  alcohol  hihders  absorption  by  the  direct  damage 
it  does  to  the  cylindrical  surface  epithelium. 

Among  gastro-enterologists  the  impression  prevails  that  alcohol 
and  alcoholic  beverages  are  capable  of  promoting  the  appetite  ;  and 
probably  for  this  purpose  and  for  its  stimulating  effect  we  arejusti- 
fied  in  giving  it.  Summing  up  the  physiological  action,  as  far  as  we 
are  concerned,  it  may  be  said:  (i)  The  effect  of  moderate  doses  of 
alcohol  on  metabolism  is  uncertain.  (2)  That  on  pepsin  hydro- 
chloric acid  it  acts  favorably  in  quantities  equal  to  one  to  two  per 
cent,  of  absolute  C2H6O,  but  beyond  that  it  gradually  inhibits  this 
action.  (3)  On  pancreatic  digestion  it  acts  unfavorably.  (4)  On 
salivary  digestion  it  acts  favorably,  increasing  the  formation  of 
maltose  when  present  in  amounts  not  exceeding  five  per  cent.  (5) 
On  the  peristalsis  it  has  no  influence  one  way  or  the  other  until 
the  amounts  exceed  six  per  cent.,  when  it  begins  to  inhibit  the 
motility.     (6)  Its  effect  on  the  rate  of  absorption  is  unknown. 

In  pathological  conditions  the  effects  of  alcohol  are  undeniably 


EFFECT    OF    MALT    LIQUORS    ON    GASTRIC    DIGESTION.  251 

different,  its  stimulating  and  temperature-depressing  influence  mak- 
ing it  of  value  in  continued  fevers.  In  pathological  cases,  wher- 
ever the  amount  of  free  HCl  is  altered,  either  in  hyperchylia  or 
achylia  gastrica,  Chittenden's  deductions  do  not  hold  good.  In 
hypochylia  or  subacidity,  alcohol  may  be  of  some  service  in  stimu- 
lating the  mucosa  to  more  prolific  secretion,  but  in  hyperchylia  it 
irritates  the  already  very  much  excited  gland-cells  still  further.  In 
achylia  with  entire  absence  of  secretion,  digestion  is  considerably 
reduced  by  alcohol.  Speaking  generally,  alcohol  might  be  dis- 
pensed with  as  a  therapeutic  and  dietetic  agent  if  it  were  not  for 
its  appetizing  and  stimulating  qualities.  In  hyperacidity  and 
hypersecretion,  in  ulcer  and  all  chronic  affections  with  augmented 
secretion,  alcohol  is  contra-indicated.  Healthy  stomachs  not 
rarely  exhibit  a  certain  adaptation  to  alcohol,  and,  naturally, 
upon  such  organs  the  agent  has  a  different  effect  than  upon  the 
stomach  of  a  teetotaler. 

Beer  has  very  little  therapeutic  utility  ;  by  reason  of  its  weight  it 
is  contra-indicated  in  all  conditions  weakening  the  gastric  wall. 
Riegel  holds  that  it  is  well  to  permit  its  use  in  simple  hyperacidity. 
It  contains  a  certain  amount  of  nutritious  matter,  and  should, 
therefore,  not  be  forbidden  if  the  patient  craves  it,  provided  the 
motor  power  is  good.  Even  the  absorption  of  less  bulky  wines  is 
attended  by  an  excretion  of  water  into  the  stomach  (von  Mehring, 
loc.  cit.),  which  may  favor  stasis  of  liquids  and  furtherance  of 
existing  dilatation. 

The  following  is  a  table  by  Roberts  ("Lectures  on  Dietetics  and 
Dyspepsia"),  showing  the  effects  of  various  percentages  of  malt 
liquors  on  gastric  digestion  : 


Proportion  of  IMalt  Liquors  in  the 


Time  in  which  Digestion  was  Completed. 
(Normal,  One  Hundred  Minutes.) 


Digesting  Mixture.  ^le.  Light  English 

Burton.  |        Table  Beer. 


Ten  per  cent., 1 15  minutes.  .  j  100  minutes 

Twenty  percent.,      140       "       .  .    115       " 

Forty  per  cent., 200       "        .  .    140       " 

Sixty  per  cent., Embarrassed        180       " 


Lager  Beer. 


100  minutes 
115       " 
140       " 
180       '• 


The  digesting  mixture   contained   two   gm.    of  dried  beef  fiber, 
0.15  per  cent,  of  hydrochloric  acid  (HCl),  and  one  c.c.  of  glycerin, 
extract  of  pepsin,  and  varying  quantities  either  of  wines  or  malt 
liquors,  and  filling  up  to  lOO  c.c.  with  water. 
19 


282 


DIETETICS    OF    ALCOHOLIC    BEVERAGES. 


The  following  table  gives  the  effects  of  various  percentages  of 
hock,  claret,  and  champagne  upon  peptic  digestion  (Roberts) : 


Proportion  of  Hock,  Claret,  or  Cham- 
pagne IN  THE  Digesting  Mixture. 


Time  in  which  Digestion  was  Completed. 
(Normal,  One  Hundred  Minutes). 


Claret. 


Champagne. 


Ten  per  cent., i  loo  minutes  . 

Twenty  per  cent., |ii5       " 

Forty  per  cent., J150       " 

Sixty  per  cent. , 1  Embarrassed 


100  minutes . 

90  mmi 

140       " 

.    100       " 

180       " 

•    130       " 

Embarrassed 

.    180       " 

In  cases  of  gastric  disease  where  great  general  debility  com- 
mands liberal  alcoholic  stimulation,  particularly  if  the  gastric 
motor  function  be  impaired,  it  is  best  to  administer  the  stimulant 
by  rectal  enema.  It  may  have  been  observed  that  most  of  the 
enemata  have  provided  for  this  emergency,  and  contain  more  or 
less  wine. 

Sir  William  Roberts  has  a  very  interesting  theory  concerning  the 
probable  utility  of  retarding  digestion  by  alcohol  : 

"  We  must  bear  in  mind  that  among  civilized  races  the  preparation 
of  food  for  the  table  is  carried  to  a  high  degree.  The  cereal  grains 
which  are  employed  to  make  bread  are  first  finely  ground  and  sifted 
from  the  bran  by  the  miller  ;  the  flour  is  then  subjected,  with  the 
aid  of  moisture  and  artificial  heat,  to  a  cooking  process  ;  the  meats 
and  fish  we  eat  are  boiled  or  roasted;  the  vegetables  we  use  are 
carefully  deprived  of  their  coarser  parts,  and  are  then  boiled.  All 
this  preliminary  preparation  and  cooking  renders  our  food  highly 
digestible  and  easy  of  attack  by  the  gastric  juices.  But  this  is  not, 
I  apprehend,  the  sole  object  in  view.  The  preliminary  preparation 
and  cooking  not  only  renders  our  food  more  digestible,  but  makes 
it  also  more  capable  of  being  more  thoroughly  exhausted  of  its 
nutritive  qualities.  These  two  objects  are  not  quite  the  same.  Even 
as  it  is,  and  with  all  this  careful  preparation,  some  waste  occurs  ; 
and  the  feces  always  contain  considerable  remnants  of  undigested 
food.  But  it  is  obvious  that,  if  food  be  rendered  too  easy  of  diges- 
tion, there  arises  a  risk  that  the  meal  will  pass  too  quickly  and 
wastefuUy  into  the  blood,  and  on  through  the  tissues  into  the 
excretory  organs,  and  so  out  of  the  body  before  it  has  been  made 
fully  and  economically  available  for  the  sustenance  of  the  slow 
nutritive  processes.  Moreover,  a  sudden  irruption  into  the  blood 
of  large  quantities  of  newly  digested  aliment  would  tend  to  disturb 


OBJECT    OF    RETARDING    DIGESTION    BY    ALCOHOL.  283 

the  chemical  equilibrium  of  that  fluid,  and  so  interfere  with  the 
tranquil  performance  of  its  functions.  It  would  also  tend  to  pro- 
duce hepatic  and  other  congestions,  to  the  general  disadvantage 
and  discomfort  of  the  economy.  A  too  rapid  digestion  and  absorp- 
tion of  food  may  be  compared  to  feeding  a  fire  with  straw  instead 
of  with  slower  burning  coal.  In  the  former  case  it  would  be 
necessary  to  feed  oftener  and  oftener,  and  the  process  would  be 
wasteful  of  the  fuel ;  for  the  short-lived  blaze  would  carry  most  of  the 
heat  up  the  chimney.  To  burn  fuel  economically,  and  to  utilize  the 
heat  to  the  utmost,  the  fire  must  be  damped  down,  so  as  to  insure 
slow  as  well  as  complete  combustion.  So  with  human  digestion 
our  highly  prepared  and  highly  cooked  food  requires,  in  the  healthy 
and  vigorous,  that  the  digestive  fires  should  be  damped  down  in 
order  to  insure  the  economical  use  of  food. 

"  In  the  plan  of  the  dietary  of  the  civilized  races,  arrived  at  slowly 
as  the  result  of  an  immense  experience,  we  seem,  therefore,  to  de- 
tect two  apparently  contradictory  aims, — namely,  on  the  one  hand, 
to  render  food,  by  preparation  and  cooking,  as  digestible  as  possi- 
ble ;  and,  on  the  other  hand,  to  control  the  rate  of  digestion  by 
the  use  of  certain  accessory  articles  with  food.  In  reality  these 
objects  are  not  contradictory  but  co-operative  to  a  beneficial  end. 
For,  to  express  the  problem  in  another  way,  it  may  be  said  that 
we  render  food,  by  preparation,  as  capable  as  possible  of  being 
completely  exhausted  of  its  nutrient  properties;  and,  on  the  other 
hand,  to  prevent  this  nutrient  matter  from  being  wastefully  hurried 
through  the  body  we  make  use  of  agents  which  abate  the  speed 
of  digestion.  This  combination  of  appliances  renders  our  plan  of 
feeding  more  elastic,  more  adaptable  to  variety  of  individual 
health  and  constitution,  and  to  variety  of  external  conditions. 

"  During  the  early  periods  of  life  retardation  of  digestion  is  less 
required  than  in  the  adult  state,  because  the  growing  organism  can 
more  fully  utilize,  in  the  work  of  the  building  up  of  the  framework, 
any  excess  of  food  which  is  poured  into  the  blood.  Accordingly, 
we  observe  that  retarding  agents  (tea,  coffee,  and  alcoholic  bever- 
ages) are  not  used  at  all,  or  only  used  sparingly,  in  the  diet  of 
infants  and  children. 

"  If  this  view  of  digestive  retardation  in  the  stomach  be  well 
founded,  the  stomach  becomes  in  some  degree  a  storage  organ  for 
food, — like  the  crop  of  birds,  the  paunch  of  ruminants,  the  dilata- 
ble cheeks  of  monkeys,  and  the  pouch  of  the  pelican." 


284  DIETETICS    OF    ALCOHOLIC    BEVERAGES. 

This  classical  writer  on  dietetics  expresses  himself  similarly 
on  the  importance  of  preparing  the  food  in  such  a  way  that  it  tastes 
cood  (Sir  William  Roberts,  /...  ciL,  "  The  Eulogium  of  the  Pal- 
ate ")  Even  Bunge,  the  well-known  physiologist,  who  is  a  pro- 
nounced teetotaler,  declares  that  we  are  justified  in  the  use  of  any 
food  or  drink  if  for  no  other  reason  but  that  it  tastes  good,  pro- 
vided  it  does  no  harm. 


CHAPTER    IV. 

LAVAGE   AND   THE  GASTRIC  DOUCHE. 

The  technics  of  lavage — the  indications  for  and  against  it — have 
been  treated  in  the  section  on  the  Stomach-tube.  In  brief,  lavage 
is  indicated,  («)  where  the  exit  of  the  chyme  from  the  stomach  is 
hindered  by  a  mechanical  obstruction,  giving  rise  to  decompositions. 
To  this  class  belong  all  forms  of  dilatation  except  those  depending 
on  simple  atony,  for  here  we  are  not  dealing  with  any  obstruction 
to  the  outflow,  but  with  a  lowering  of  the  peristalsis,  which  is  not 
markedly  benefited  by  lavage.  Dilatations  that  indicate  lavage  are 
those  due  to  cicatricial  stenosis,  or  neoplasm  of  the  pylorus  and 
duodenum,  and  impairment  of  motor  function  in  consequence  of 
carcinoma,  sarcoma,  syphilitic  and  tuberculous  gastritis,  atrophic 
gastritis,  myasthenia,  corrosive  contractions  caused  by  acids  and 
alkalies.  The  benefit  derived  from  lavage  must  vary  with  the  stage 
at  which  the  treatment  is  undertaken.  In  cases  of  cicatricial 
stenosis  of  mild  and  incipient  character,  the  dilatations  have  been 
cured  by  lavage,  probably  because  a  compensatory  hypertrophy 
of  the  musculature,  developing  gradually,  enabled  the  organ 
to  expel  the  chyme.  In  these  gastrectasias,  the  stomach,  after 
the  systematic  lavage  treatment,  no  longer  contained  food  and  HCl 
in  large  quantities  in  the  morning.  The  stools  and  the  quantity  of 
the  urine  became  normal,  and  the  patients  could  tolerate  an 
ordinary  diet.  But  such  cases  must,  even  after  recovery,  avoid 
overloading  the  stomach,  as  this  has  been  known  to  bring  about 
relapse. 

{b)  The  second  main  indication  is  where  foreign  or  irritating 
collections  are  mixed  with  the  gastric  contents,  which  sooner  or 
later  interfere  with  digestion.  These  collections  may  consist  of 
abnormally  augmented  gastric  juice,  of  gastric,  pharyngeal,  and 
esophageal  mucus,  and  of  bile.  In  hypersecretion  lavage  is  best 
carried  out  with  sodium  bicarbonate,  and  thereafter  with  argentic 
nitrate  or  bismuth  subnitrate.  The  pyrosis,  constipation,  and  dis- 
tention are  much  relieved  thereby.  In  cases  of  much  accumulation 
of  mucus,  warm  alkaline  and  saline  solutions  are  preferable;  for  in 

285 


286  LAVAGE    AND    THE    GASTRIC    DOUCHE. 

the  gastritis  mucosa  the  HCl  secretion  is  lost,  and  common  salt  is 
a  stimulation  to  that  secretion — if  there  be  any  secreting  glands 
left.  Toxic  products  of  complex  nature  may  accumulate  in  the 
organ,  in  consequence  of  carcinoma,  uremia,  and  diabetes  mellitus  ; 
here  lavage  is  also  indicated.  During  the  lavage  one  should 
always  have  a  second  glass  vessel  holding  one  liter,  into  which 
the  outflow  discharges,  so  that  it  may  be  ascertained  each  time 
how  much  is  regained.  It  is  very  dangerous  to  wash  out  the 
stomach  with  medicated  and  antiseptic  solutions  without  ascertain- 
ing whether  all  the  solution  flows  out  again.  Even  with  simple 
water,  overloading  of  the  stomach  can  not  be  avoided  except  by 
measuring  the  outflow.  In  a  paper  published  in  the  Practitioner 
(1892,  No.  4),  W.  Soltau  Fenwick  reports  three  cases  of  poisoning 
from  leaving  antiseptic  solutions  in  the  stomach.  In  one  case 
{Schmidt's  Jalirbucher,  1883,  Bd.  cxcviii,  p.  28),  death  was  caused 
in  six  days  by  leaving  a  two  to  three  per  cent,  solution  of  boric  acid 
in  the  stomach.  Fenwick  also  makes  a  strong  plea  against  the  indis- 
criminate use  of  antiseptics  within  the  stomach,  for  the  alimentary 
canal  is  "  endowed  with  the  power  of  absorbing  not  only  the 
poisonous  products  of  the  bacteria,  but  also  most  of  the  substances 
which  are  introduced  to  destroy  them  "  (W.  S.  Fenwick,  "  Disorders 
of  Digestion  in  Infancy,"  etc.,  p.  141). 

Tetany  has  been  observed  after  lavage  by  Bouveret  and  Devic, 
who  collected  21  cases  {Revtie  de  Med.,  February,  1892).  In  all, 
34  such  cases  of  tetany  of  gastric  origin  have  been  reported,  though 
not  all  due  to  lavage.  Ewald  reported  two  cases  that  are  of  interest 
in  this  connection, — one  a  male,  aged  forty-five,  who  died  from  a 
sudden,  copious,  esophageal  hemorrhage  two  days  after  he  had 
sought  relief  by  introduction  of  the  esophageal  sound.  There 
were  symptoms  of  mediastinal  tumor  or  aneurism.  The  second 
patient  died  suddenly  while  he  was  introducing  the  tube  himself; 
the  autopsy  showed  a  dissecting  aneurism  at  the  beginning  of 
the  ascending  aorta,  still  within  the  pericardium.  Frerichs  and 
Penzoldt  have  reported  similar  cases.  Moral  :  Examine  every  new 
patient  carefully  for  abnormal  conditions  within  the  thorax  before 
lavage. 

The  Gastric  Douche. — By  douching  the  stomach  is  meant  an 
internal  irrigation  with  water  under  high  pressure.  It  was  first 
practised  at  Kussmaul's  clinic,  and  described  later  by  Malbranc 
("  On    the    Treatment    of    Gastralgias    by    the    Internal    Gastric 


THE    GASTRIC    DOUCHE. 


287 


Douche,"  etc.,  Berlin,  klin.  Woclienschr.,  1878,  No.  4).  It  does  not 
differ  essentially  from  ordinary  lavage  except  in  the  fact  that  the 
funnel  or  vessel  into  which  the  water  is  poured  is  held  at  least 
one  meter  above  the  cardia.  Rosenheim  improved  and  revived 
the  method,  after  it  had  been  disregarded  for  twelve  years,  by  devis- 
ing a  special  douching  tube  with  numerous  very  small,  lower  open- 
ings instead  of  one  or  two  large  ones.  Water  that  is  allowed  to 
run  into  the  stomach  through  such  a  tube  under  high  pressure, 
strikes  the  walls  in  the  form  of  a  drizzling  rain,  with  many  cur- 
rents of  considerable  impetus.  The  central  or 
terminal  opening  in  Rosenheim's  douche  tube  is 
larger  than  the  lateral  ones,  and  permits  of  an 
easy  outflow.  Dr.  F.  B.  Turck,  of  Chicago,  has 
devised  a  stomach  needle  douche  with  a  separate 
outflow  tube ;  it  also  produces  an  intragastric 
shower  (Fig.  26). 

Rosenheim  recommends  the  douche  for  nervous 
dyspepsia  and  chronic  gastritis,  with  or  without 
impaired  motility.  If  the  douching  was  done 
with  solution  of  sodium  chlorid  an  increase  in 
the  HCl  production  could  be  ascertained  ;  whereas 
nitrate  of  silver  caused  a  reduction  of  the  secre- 
tion {Berlin.  Klinik,  1894,  Heft  71).  Riegel 
speaks  well  of  argentic  nitrate  applied  in  this 
manner  for  all  irritative  states  of  secretion  {loc. 
cit.,  p.  300 j. 

Fleiner  has  called  attention  to  the  fact  that  he 
and  Kussmaul  could  incite  a  feeling  of  hunger  by 
these  douches.  These  clinicians  increased  the 
effect  by  irrigating  the  gastric  mucosa  with  solu- 
tions of  bitter  tonics,  of  which  extracts  or  solu- 
tions of  hops  and  quassia  were  experimented  with. 

In  severe  cases  of  anorexia  we  have  tried  this  method  with  in- 
fusions of  gentian  and  cinchona,  and  were  pleased  with  the  effects. 
Einhorn  has  invented  an  intragastric  spray  (Fig.  27),  which  is  recom- 
mended for  disinfection  of  the  mucosa,  to  produce  an  astringent  or 
an  anesthetic  effect.  Upon  Einhorn's  solicitation  we  experi- 
mented with  a  spray  presented  by  him,  and  have  never  since  been 
without  one.  It  is  surprising  what  a  trifling  amount  of  cocain 
is  necessary  to  relieve  a  gastralgia  when  used  in  this  manner.     For 


V/h 


Fig.  26. — Recurrent 
Gastric  Needle 
Spray  or  Douche. 


250  LAVAGE    AND    THE    GASTRIC    DOUCHE. 

gastric  erosions  the  nitrate  of  silver  spray  (i  :  looo)  is  frequently 
curative.  The  gastric  douche  and  spray  should  only  be  applied 
in  an  empty  stomach.  Motor  impairment  of  nervous  origin  is 
occasionally  much  improved  by  alternately  douching  with  warm 
(iOO°  C.)  and  cold  water. 

Electricity  in  the  Treatment  of  Gastric  Diseases. — The  effect' 
of  electricity  on  the  various  functions  of  the  stomach  have  been 
already  referred  to  under  the  consideration  of  the  motor  function  and 
will  be  further  described  under  the  various  diseases  in  which  it  is 
recommended.  The  results  of  physiological  experiment  and  of  clini- 
cal experience  are  largely  contradictory.  Physiological  experiments, 
when  conducted  by  medical  men,  are  frequently  inexact  and  mislead- 
ing. It  requires  special  physiological  laboratory  training  of  years  to 
control  the  technics  of  vivisection.     In  the  experiments  of  medical 


""'■"  G.TIf  MANNS-CO. 

Fig.  27. — Einhorn's  Intragastric  Spray. 

men  on  the  physiological  effects  of  electricity  it  is  not  difficult  to  find 
numerous  defects  in  the  physics  and  physiology  of  the  methods  used, 
the  conduct  and  the  execution  of  the  experiment,  etc.,  which  render 
their  results  invalid  from  the  outset ;  so  that  it  is  useless  to  go  into 
the  literature  of  the  history  of  gastric  electrotherapy  exhaustively. 
Many  experimenters  fail  to  give  the  details  and  conditions,  the  kind 
of  cell  used,  the  number  of  milliamperes,  the  number  of  faradic 
stimulations  to  the  minute,  the  kind  of  electrode,  the  distance  of 
primary  from  secondary  coil.  Control  experiments  are  wanting  to 
ascertain  whether,  in  the  same  animal,  peristalsis  could  not  be 
observed  pe7^  i'^  without  stimulation  by  electricity,  or  whether  the 
stimulation  may  not  have  been  purely  mechanical,  not  electrical. 

From  a  clinical  standpoint  it  is   not   necessary  to   demonstrate 
that  electricity  can  produce  changes  in  the  chemistry,  resorption. 


EFFECT  OF  ELECTRICITY  ON  SECRETION.  289 

and  motility  of  the  stomach  in  order  to  justify  its  employment  ; 
for  there  may  be,  and  probably  are,  influences  exerted  by  elec- 
tricity upon  the  nutrition  of  living  cells  which  as  yet  escape  our 
methods  of  analysis.  The  effect  of  electrical  stimulation  of  the 
cells  of  spinal  ganglia,  as  seen  and  determined  by  micrometric 
measurement,  and  consisting  in  a  loss  of  bulk  mainly  in  the  nuclei, 
was  first  described  by  C.  F.  Hodge,  in  the  American  Jour,  of  Psy- 
chology for  May,  1888,  and  May,  1889.  Judging  from  these  experi- 
ments, which  were  conducted  with  exemplary  accuracy  and  regard 
for  physiological  detail,  it  is  reasonable  to  presume  that,  in  some 
way  or  other,  the  metabolism  of  muscle-,  gland-,  and  nerve-cells  of 
the  stomach  may  be  influenced  by  electricity.  The  demonstration 
of  this  is  a  future  prospect;  at  present  the  main  reason  we  employ 
this  agent  is  simply  because  we  know  that  in  certain  diseases  it 
does  good.  Physiology  may  come  to  our  aid  later  on,  and  tell  us 
why  it  is  that  these  results  are  produced.  From  the  work  done  by 
medical  physiologists  so  far,  no  clear  deductions  are  possible. 

The  electrical  stimulation  of  the  vagus  in  a  subject,  forty-five 
minutes  after  execution,  which  was  carried  out  by  Beynard  and 
Loye  {Progres  Medicale,  1885,  No.  29),  and  produced  a  secretion  of 
gastric  juice,  has  strengthened  the  belief  that  the  vagus  contains 
gastric  secretory  fibers.  Zievassen  JKlinische  Vorirdge,  No.  12, 
1887),  Rossi  {Lo  Sperim.,  1881),  and  Hoffmann,  who  experimented 
at  Riegel's  clinic  {Berlin,  klin.  WochenscJir.,  1889,  No.  12),  all 
arrived  at  the  conclusion  that  electricity  promoted  the  secretion  of 
gastric  juice. 

The  results  of  investigations  concerning  the  influence  of  the  two 
kinds  of  currents — the  constant  and  the  interrupted — differ  widely. 
Einhorn  was  of  the  opinion  that  the  faradic  current  promoted 
secretion  and  the  galvanic  impeded  it  [Deutsche  med.  JVochenschr., 
1893;  also  Zeitschr.  f.  klin.  Med.,  Bd.  xxiii).  The  experiments  of 
Hoffniann  {loc.  cit)  suggested  that  the  galvanic  current  favored  an 
increased  secretion,  while  Bocci's  results  with  intragastric  faradiza- 
tion would  have  us  believe  that  in  animals  the  interrupted  current 
can  augment  both  peristalsis  and  secretion  [Lo  Sperinicntale, 
Giugno,  1881). 

Concerning  the  effect  of  electricity  on  the  motor  function  we 
might  quote  a  few  experimenters.  Schillbach  {Virchoivs  Arch.,  Bd. 
cix,  p.  284)  produced  strong  contractions  at  the  site  of  the  anode 
by  applying   the   galvanic   current   to   the   intestines   of  a   rabbit. 


290  LAVAGE    AND    THE    GASTRIC    DOUCHE. 

Von  Ziemssen  {loc.  cit.),  Bocci  {loc.  cit.),  Ludwig,  and  Weber  have 
stated  that  the  faradic  as  well  as  the  galvanic  current  applied 
directly  to  the  stomach  cause  contraction  of  the  same  in  animals. 
Fubini  {^Centralbl.f.  vied.  IViss.,  1882,  No.  33)  concluded  that  elec- 
tricity accelerates  intestinal  peristalsis  ;  he  experimented  on  Vella's 
double  intestinal  fistula.  Two  Americans,  Rockwell  and  Beard 
{PJiiladelpJiia  Medical  and  Surgical  Report.,  1868,  No.  20),  were 
among  the  first  to  employ  electricity  in  the  treatment  of  nervous 
dyspepsia. 

In  Pepper's  case  of  spontaneous,  visible,  gastric  peristalsis  {PJiila. 
Med.  Times,  1871,  p.  274)  no  peristaltic  movements  could  be  pro- 
duced by  applying  electricity  percutaneously.  Kussmaul,  in  1877, 
stated  that  "  the  therapeutic  results  obtained  by  Fuerstner  in  gas- 
trectasias  did  not  prove  that  an  actual  peristalsis  was  produced  by 
the  current,  but  they  were  probably  due  to  contraction  of  the 
abdominal  muscles"  [ArcJiiv  f.  Psycliiatrie  ti.  Nervenkrankli.,  1878, 
p.  205).  Canstatt  first  suggested  treating  dilatations  by  placing 
one  electrode  in  the  esophagus,  the  other  on  the  stomach  ;  and 
Duchenne  first  actually  applied  this  method  (both  the  latter 
quoted  from  Kussmaul  [loc.  cit?).  In  1877,  Kussmaul  {loc.  cit?) 
began  introducing  intragastric  electrodes,  made  by  inserting  a 
copper  wire  in  a  stomach-tube,  the  wire  terminating  in  a  little 
exposed  knob  which  came  in  direct  contact  with  the  inner  gastric 
surface. 

Bardet  improved  this  method  by  a  similar  electrode,  which,  how- 
ever, did  not  come  in  contact  with  the  mucosa  in  one  spot  only, 
but  by  a  quantity  of  water  previously  taken  it  was  distributed  over 
the  entire  surface  (Bardet,  Bull.  Gen.  de  Therap.,  1884).  Ziemssen 
then  employed  a  similar  device,  but  Einhorn  completed  the  evolu- 
tion of  the  intragastric  electrode  by  originating  a  soft,  very  plastic, 
deglutable  instrument,  the  end  of  which  is  inclosed  in  an  ovoid, 
perforated,  hard-rubber  cap.  Ewald  prefers  Einhorn's  electrode  a 
little  more  rigid,  so  that  it  can  be  pushed  into  the  stomach  and 
need  not  necessarily  be  swallowed.  The  thickness  of  the  rubber 
tube  in  Ewald's  modification  is  i^  mm.  Rosenheim  [loc.  cit?), 
Wegele  {Therap.  MonatsJiefte,  April,  1895),  Charles  G.  Stockton 
("A  New  Gastric  Electrode,"  Medical  Record,  Nov.  9,  1889), 
and  F.  B.  Turck  have  later  devised  electrodes  for  this  purpose 
which  represent  no  advance  over  those  mentioned.  The  thin- 
wired  electrode  of  Einhorn  (Fig.  29)  possesses  the  advantage  that  it 


EFFECT    OF    ELECTRICITY    ON    GASTRIC    PERISTALSIS. 


291 


can  be  swallowed  by  those  not  used  to  the  stomach-tube,  to  which 
they  must  become  accustomed  in  case  Wegele's,  Stockton's,  or 
Rosenheim's  electrode  is  employed.  The  inclosing  tube  of  Ein- 
horn's  instrument  is  really  too  thin,  however,  for  in  our  experience 
it  rapidly  wears  through  near  the  connection  with  the  hard-rubber 
end-cap,  and  we  consider  Ewald's  modification  safer  and  more 
durable. 

For  more  complete  literature  of  the  subject  the  reader  is  referred 
to  the  writings  of  Kussmaul  (loc.  cit.),  Einhorn  {loc.  cit.,  and  Ein- 
horn,  Berlin,  klin.  Woclienschr.,  1891,  Xo.  23  ;  also  Zeitsdir.  f.  klin. 
Med.,   1893,  XXIII,  p.   369),  and    Goldschmidt  {Dejitsches  Archiv  f. 


Fig.  2S. — Rectal  Electrode. 


GEO.TIEMANN   CO. 
Fig.  29. — Einhorn's  Intragastric  Electrode, 


kliit.  Med.,  Bd.  xv,  p.  295).  The  latter  investigator  worked  under 
Moritz,  whose  capital  experiments  on  the  motility  we  have  already 
abstracted.  Goldschmidt  concludes  that  the  "  direct  faradization 
and  galvanization  of  the  stomach  (distance  of  primary  from 
secondary  coil  =  zero,  duration  fifteen  to  twenty-five  minutes)  has 
only  an  unimportant  and  inconstant  influence  on  the  peristalsis, 
and  on  secretion  it  has  no  influence  whatever." 

These  results  correspond  in  the  main  with  those  pre\-iously 
published  by  ^leltzer  {Xczv  York  Med.  Jour.,  June  15,  1S95), 
whose  experiments  were  conducted  with  great  care,  and  from  a 
physiological  aspect  are  be\-ond  reproach.     \\"e  would  have  pre- 


292  LAVAGE    AND    THE    GASTRIC    DOUCHE. 

ferred  knowing  how  man\-  vibrations  to  the  second  jMeltzer  used, 
since  we  have  assured  ourselves  that  when  too  many  stimulations 
to  the  second  are  thrown  into  a  muscle,  particularly  an  involuntary 
muscle,  it  will  not  contract  at  all ;  whereas  the  same  muscle  will 
contract  if  a  smaller  number  of  stimulations  be  used  (judged  by 
the  Kronecker  interrupter  and  a  Jacquet  chronograph).  These 
facts  were  first  stated  in  an  article  in  the  Niw  York  Med.  Jotir. 
(Hemmeter  "  Recording  Motor  Functions  of  the  Stomach,"  New 
York  Med.  Jour.,  June  22,  1895,  p.  772).  We  used  an  intragastric 
deglutable  rubber  bag  (see  illustrations,  Plate  iv),  which  had  small 
brass  knobs  extended  at  any  desirable  location,  and  when  the  bag 
was  distended  b}'  blowing  it  up  within  the  stomach,  the  end 
electrodes  pressed  directly  against  the  mucosa, — usually  one  at  the 
pylorus  and  one  in  the  fundus  ;  the  bag  was  in  connection  with  a 
tambour  or  manometer  recording  on  the  Ludwig  kymographion. 
We  have  already  briefly  stated  that  we  were  unable  to  produce  any 
contraction  of  the  human  or  animal  stomach  with  the  strongest  cur- 
rents to  be  obtained  from  one  Grove's  cell  prepared  anew  for  each 
experiment,  and  the  distance  of  the  primary  from  the  secondary  coil 
equal  to  zero  when  both  electrodes  were  within  the  stomach  touching 
the  mucosa.  We  have  elsewhere  given  our  studies  on  the  resistance 
which  fresh  human  gastric  mucosa  offers  to  the  constant  current, 
and  in  the  main  can  confirm  Meltzer  that  percutaneous  and  direct 
faradization  of  the  stomach  and  intestines  can  produce  no  contrac- 
tion of  these  parts.  Not  every  current  which,  according  to  mag- 
netic needles  or  the  milliampere  meter,  actually  penetrates  the 
gastric  wall,  causes  contraction.  For  instance,  with  one  electrode 
within  the  stomach  of  man  or  dog,  and  another  on  the  gastroc- 
nemius, the  skeletal  muscle  may  contract  vigorously  and  the 
stomach  remain  passive.  Again,  in  human  subjects,  the  factors  of 
natural  peristalsis  occurring  under  the  nervous  tension  due  to  the 
experiment,  and  of  suggestion,  can  not  be  satisfactorily  eliminated. 
In  a  recent  publication  Einhorn  has  attempted  to  disprove  the 
experiments  of  Meltzer,  but  as  far  as  can  be  judged  from  the  report 
of  the  former  (in  the  Archiv  f.  Verdaiiungskrankhciten,  von  Boas^ 
Bd.  II,  p.  454),  the  experiments  were  not  conducted  along  the  same 
lines  nor  with  the  same  regard  for  physiological  detail  as  those  of 
Meltzer.  Einhorn  gives  brief  synopses  of  18  experiments,  12 
of  which  were  made  with  frogs,  which  Meltzer  did  not  work  with, 
and  from  the  results  of  which  conclusions  reg-ardine  the  mamma- 


EFFECT    OF    ELECTRICITY    ON    PERISTALSIS.  293 

lian  stomach  are  not  applicable.  Three  animals  were  rabbits ;  in 
these  the  stomach  is  always  full  of  ingesta,  unless  starved.  Two 
were  rats;  one  only  was  a  dog;  this  last  was  the  animal  with 
which  Meltzer  mainly  worked.  Nor  is  it  evident  that  Einhorn's 
results,  as  stated  by  him,  contradict  those  of  Meltzer  in  salient 
points.  Taking,  for  instance,  the  last  experiment — No.  i8 — with 
the  dog;  here  Einhorn  made  three  kinds  of  stimulations  with  the 
double  electrode:  (i)  on  the  serous  (peritoneal)  surface,  near 
fundus — contraction  ;  (2)  on  the  peritoneal  surface  over  the  pylorus 
— strong  contraction ;  (3)  opening  of  the  stomach, — one  electrode 
against  the  mucosa,  the  other  on  the  peritoneal  layer  outside  ;  a 
weak  current  causes  slight  peristaltic  contractions. 

Meltzer  does  not,  in  his  original  paper,  deny  any  of  these  possi- 
bilities ;  even  the  contraction  of  the  third  stimulation  experiment 
was  witnessed  by  him  when  the  inner  electrode  on  the  mucosa 
was  placed  .near  the  outer  one  on  the  serosa.  But  with  bipolar 
internal  stimulation — i.  e.,  with  both  electrodes  on  the  mucosa — 
even  Einhorn  does  not  claim  to  have  obtained  any  peristalsis  of 
considerable  tonicity.  We  incline  to  the  opinion  that  satisfactory 
evidence  has  ;/c/ yet  been  furnished  that  internal  electric  stimula- 
tion can  influence  secretion  or  motility  either  way.  This  conclu- 
sion has  been  reached  after  years  of  experimenting  on  both 
functions  in  the  Biological  Laboratory  of  the  Johns  Hopkins 
University. 

In  a  recent  reply  to  Einhorn's  criticism,  Meltzer  accepts  the 
explanation  of  the  former,  concerning  the  difficulty  of  penetration 
of  the  electric  current  to  the  muscular  layer  [Boas'  Archiv  f. 
Verdauungskrankh.,  Bd.  iii.  Heft  2,  S.  133).  This  may  be  caused, 
according  to  Einhorn,  by  the  mucosa  being  a  bad  conductor  as  well 
as  by  its  being  a  very  good  conductor — leading  the  current  away 
from  the  point  of  contact.  We  have  shown  conclusively  that  the 
fresh  normal  human  mucosa  is  a  poor  electric  conductor.  Einhorn, 
however,  assumes  that  the  mucosa  conducts  so  well  that  the  cur- 
rents does  not  reach  the  muscularis,  because  it  moves  in  the  direc- 
tion of  least  resistance — in  the  glandular  layer  itself  Tests  made 
with  the  mucosa  peeled  off  from  the  other  layers  of  the  stomach  of 
a  dog  under  narcosis,  with  the  milliamperemeter  in  the  circuit, 
show  that  fresh  mucosa  is  practically  a  non-conductor. 

Indications  for  the  Employment  of  Electricity  a7td  Maimer  of  Appli- 
cation.— Direct  gastric  faradization  is  recommended  for  dilatations 


294  LAVAGE    AND    THE    GASTRIC    DOUCHE. 

due  to  relaxation  of  the  musculature,  but  not  to  stenosis,  whether 
these  cases  are  associated  with  reduced  secretion  or  not.  Re- 
laxations of  the  cardia  or  pylorus  are  benefited  by  the  faradic 
current.  Sensory  disorders  (gastralgia)  are  successfully  treated  with 
direct  galvanization.  To  these  statements  we  can  give  our  approval, 
although  other  clinicians  differ  slightly  from  Einhorn.  Thus, 
Rosenheim  {loc.  cit.)  believes  that  the  galvanic  current  is  more 
effective  in  debility  of  the  peristalsis.  In  all  symptoms  of  sensory 
irritation  he  prefers  the  constant  current  also,  but  in  secretory  dis- 
turbances he  has  ceased  to  use  electricity ;  and  we  agree  with  him 
that,  in  the  latter  class,  more  can  be  accomplished  by  medicated 
douches,  and  adapted  acid  or  alkaline  and  bitter  tonic  medicines, 
than  with  electricity.  Brock  confirms  the  good  effect  of  galvanism 
on  the  course  of  gastric  neuroses  {TJierap.  MonatsJiefte ,  June,  1895), 
though  he  is  not  so  enthusiastic  as  Einhorn. 

According  to  Goldschmidt,  there  are  no  distinct  differences 
between  the  effects  of  direct  galvanization  and  direct  faradization  ; 
but  nevertheless  he  recommends  the  former  for  the  painful,  the 
latter  for  the  functional  disturbances  of  the  stomach.  In  contrast 
with  those  mentioned,  von  Ziemssen  prefers  the  percutaneous  to  the 
direct  intragastric  application  ;  his  reasons  are  not  very  convincing, 
in  the  light  of  Meltzer's  and  Goldschmidt's  experiments.  The 
electric  brushing  of  the  skin  of  the  abdomen,  breast,  and  back, 
urged  by  von  Ziemssen,  seems  to  be  a  great  stimulus  for  nervous 
energy  in  neuropathic  cases. 

In  this  country,  Allen  A.  Jones  (J/^^.  i?^^.,  June  13,  1891),  Charles 
G.  Stockton  {Med.  Rec,  1889,  p.  530),  and  D.  D.  Stewart  {Therap. 
Gazette,  1893,  p.  744),  have  published  clinical  observations  on 
the  intragastric  employment  of  electricity,  and  there  is  a  fairly 
uniform  agreement  that  the  class  of  gastric  neuroses,  particularly 
the  sensory  neuroses,  nervous  vomiting,  and  anorexia,  are  special 
indications  for  electricity  in  the  form  of  the  constant  current,  and 
that  the  direct  intragastric  method  is  to  be  preferred  to  the  per- 
cutaneous. 

In  simple  atony  and  atonic  dilatations  (but  not  in  those  depen- 
dent upon  pyloric  obstruction)  the  preference  is  to  be  given  to  the 
direct  faradic  current.  The  manner  of  application  is  simple  ;  the 
anode  is,  as  a  rule,  swallowed,  and  forms  the  intragastric  pole. 
The  cathode  must  have  the  shape  of  a  conveniently  broad  and  long, 
felt-covered  plate  (Fig.  30),  which,  after  it  is  dipped  in  warm  water,  is 


HYDROPATHIC    AND    ORTHOPEDIC    METHODS 


295 


placed  for  ten  minutes  on  the  epigastrium  ;  thereafter  passed  slowly 
up  and  down  over  the  spinal  column  from  the  cervical  to  the  sacral 
region.  The  meter  showing  about  25  milliamperes  should  always 
be  in  the  circuit,  in  case  the  galvanic  current  is  used.  For  the 
faradic  current  we  employ  the  full  strength  of  three  dry  cells 
(chlorid  of  silver),  and  gradually  increase  to  six  cells.  The  elec- 
tric bath,  or  electricity  applied  when  the  body  is  immersed  in  a 
saline  bath,  has  its  advantages  in  gastric  neuroses. 

Hydrotherapeutic  and  Orthopedic  Methods. — Mydriatic  pro- 
cedures are  much  lauded  by  German  and  French  gastro-enterolo- 
gists.  Most  of  these  methods  can  only  influence  the  stomach 
indirectly  and  secondarily,  and  therefore  are  of  greater  utility  in 
functional  disturbances  than  in  the  organic  gastric  diseases.  These 
methods  may  be  divided  into  (i)  general  or  systemic,  (2)  special 
or  local  hydrotherapic  treatments.  The  method  to  employ  depends 
more  upon  the  state  of  general 
health  and  the  condition  of 
the  nervous  system  than  upon 
any  local  condition.  Wherever 
hydriatic  treatment  becomes 
necessary,  it  is  imperative  to 
send  the  patient  to  some  well- 
managed  institution,  as  most  of 
the  procedures  can  not  be  ex- 
ecuted at  home.  Among  the 
methods  most  employed  are 
the  various  local  and  general  douches,  viz.,  fan  douche,  cold,  hot, 
graduated,  Scotch,  and  French  douches.  Among  these  we  have 
tried  the  Scotch  douche  most  frequently  in  gastric  myasthenia.  It 
consists  of  a  stream  of  moderate  intensity  directed  against  the 
epigastrium  for  three  or  four  minutes.  But  during  this  time  the 
temperature  of  the  water  is  changed  every  ten  or  twenty  seconds 
from  28°  to  8°  R.,  or  vice  versa ;  it  is  much  lauded  by  von  Ziemssen 
and  Rosenthal  ("  Magenneurosen,"  etc.,  Wien,  1886).  There  are, 
besides,  many  kinds  of  fine  sprays,  and  the  sponge,  sea  salt,  pour, 
dash,  shower,  shallow,  vapor  and  sitz-baths  ;  also  the  various  packs, 
fomentations,  and  compresses.  A  local  application  which  is  very 
soothing  in  gastralgic  affections  is  the  so-called  Priessnitz  pack, 
which  consists  simply  of  a  towel  folded  together  to  the  size  of  six  by 
ten  inches,  and  dipped  into  hot  or  cold  water,  and  then  wrung  out 


Fig.  30. — Abdominal  Electkode. 


296  LAVAGE    AND    THE    GASTRIC    DOUCHE. 

SO  that  there  is  no  dripping  from  it,  and  then  applied  to  the  epigas- 
trium ;  a  layer  of  oiled  silk  or  gutta-percha  paper  is  laid  over  it  and 
the  whole  is  snugly  secured  and  held  in  place  by  a  broad  flannel 
bandage  passed  around  the  body.  As  a  matter  of  fact,  most 
patients  feel  relieved  and  free  from  pain,  but  how  the  quieting 
effect  is  produced  is  a  matter  of  conjecture. 

In  the  treatment  of  gastric  ulcer  hot  cataplasms  are  very  service- 
able. We  are  in  the  habit  of  using  spongiopiline  dipped  into  hot 
water  and  applied  to  the  epigastrium  after  the  excess  of  water  is 
pressed  out. 

In  the  first  volume  of  Hare's  "  System  of  Practical  Therapeutics," 
Dr.  Simon  Baruch  has  an  interesting  article  on  "  Hydrotherapy  and 
Mineral  Waters,"  in  which  the  rationale  of  the  action  of  water, 
peripheral  irritation  on  temperature  changes,  and  the  technic  of 
hydrotherapy  are  instructively  described. 

The  orthopedic  appliances  used  in  the  treatment  of  gastric  dis- 
eases are  often  only  imperfect  substitutes  for  the  more  lasting 
effects  of  proper  operations.  They  consist  of  contrivances  to  sup- 
port the  stomach  in  gastroptosis,  or  to  keep  up  a  floating  kidney 
and  prevent  its  interfering  with  the  gastric  or  intestinal  peristalsis. 
Where  the  abdominal  muscles  have  become  so  relaxed  that  they 
seem  to  drag  the  viscera  downward  instead  of  supporting  them,  a 
condition  found  in  obesity  (Hangebauch),  the  Landau  abdominal 
corset,  for  both  sexes,  is  recommended  by  Riegel.  Abdominal 
gymnastics  are  the  most  effective  prophylaxis  against  these  condi- 
tions. 

Gastric  Massage. — Von  Ziemssen  ("Ueber  d.  physik.  Behandl. 
chronisch.  Magen-  u.  Darmleiden,"  Leipzig,  1888,  p.  29)  and  Rosen- 
heim {loc.  cit.,  p.  146)  consider  massage  a  very  subordinate  means  of 
treatment  for  stomach  diseases.  Ewald  {loc.  cit.),  Boas  {loc.  cit.),  and 
Riegel  {loc.  cit}),  however,  believe  that  there  is  something  of  value 
in  the  treatment.  The  best  study  of  gastric  massage  was  published 
by  Zabludowsky  {Berlin,  klin.  Wochenschr.,  1886,  No.  26)  and  Cseri 
{Wien.  Died.  WochenscJir.,  1889).  The  technic  of  massage  differs 
according  to  the  object  to  be  accomplished.  If  it  is  intended  as  a 
passive  exercise  to  strengthen  the  musculature,  it  is  best  done  on 
an  empty  stomach,  in  bed  before  breakfast.  But  if  the  massage  is 
expected  to  assist  in  the  expulsion  of  chyme,  it  should  be  under- 
taken three  to  four  hours  after  the  principal  meals.  Massage  can 
not  be  properly  performed  except  on  the  uncovered  skin.     Indica- 


INDICATIONS    FOR    GASTRIC    MASSAGE. 


297 


tions  for  massage  are  given  in  the  disturbances  of  the  motor  func- 
tions, viz.:  (i)  Those  depending  on  myasthenia  or  atony;  (2) 
depending  on  a  stenosis  of  moderate  degree;  (3)  cases  of  reduced 
secretion  and  chronic  gastritis ;  (4)  gastroptosis  or  prolapse  of  the 
stomach  ;  and  (5)  certain  cases  of  nervous  inhibition  of  peristalsis. 
In  cancer,  ulcer,  hematemesis,  all  acute  inflammations  in  or  around 
the  organ,  in  excessive  dilatation,  distention,  or  contraction,  and  in 
all  cases  of  intragastric  putrefaction,  massage  is  contra-indicated. 


Fig.  31. — Massage  of  the  Stomach  in  Dilatation  or  Gastroptosis.     {Penzoldt  and  Siintzing, 
"  Handduch  d.  Therapie,"  etc.) 


The  technic  varies  with  the  indication.  For  improving  the 
muscular  tone  of  the  empty  stomach,  the  masseur  places  himself 
to  the  right  of  the  patient,  who  must  lie  on  his  back  with  knees 
slightly  flexed.  First  movement  [a) :  Insert  the  left  hand  deeply 
under  the  left  arch  of  false  ribs,  under  and  past  the  edge.  To  increase 
the  pressure,  gently  press  the  right  hand  firmly  on  the  left.  Second 
20 


298 


GASTRIC    MASSAGE. 


Fig    ■^■2  —Massage  for  Improving   Gastric  Tonicity.      (Penzoldt  and  Stintzing,  "  Handbuch  d. 

Therapie,  etc") 


(r^-h. 


Fig.  33.— Massage  op  the  Stomach  and  of  the  Colon.      {Penzoldt  and  Stintzing,  "  Handbuch 

d.   Therapie,"  etc.) 


TECHNICS    OF    GASTRIC    MASSAGE.  299 

mov^ement  {b) :  Now  describe  small  circles  with  the  hands  thus  ar- 
ranged, progressing  slowly  from  the  pylorus  to  the  fundus.  Third 
movement  [c) :  Perform  strong  vibratory  movements  toward  the 
depth  with  the  finger  tips  while  a  and  d  are  being  executed. 
Fourth  movement  (d):  Knead  the  stomach  between  thumb  and 
four  fingers,  and  in  conclusion  execute  stroking  passes,  with  ex- 
tended four  fingers,  from  left  to  right. 

]\Iassage  of  the  full  stomach  is  undertaken  with  a  view  to  mix  its 
contents  thoroughly  or  to  aid  in  forcing  them  into  the  duodenum. 
Zabludowski  {loc.  at.)  advises  the  pressing  of  the  stomach  against 
the  spinal  column,  dividing  it  into  two  halves ;  by  compressing  the 
half  nearest  the  pylorus,  he  widens  the  latter  by  wedging  the 
chyme  through  it  into  the  duodenum.  This  is  justifiable  only 
where  it  is  sure  that  the  chyme  is  comparatively  fresh  and  not  in  a 
state  of  putrefaction. 


CHAPTER  V. 
MINERAL   SPRINGS. 

The  Uses  and  Abuses  of  Natural  Mineral  Waters  in  Diseases  of  the 
Digestive  Organs.^ 

With  such  a  wealth  of  valuable  mineral  springs  in  this  country, 
it  is  difficult  to  understand  the  large  annual  exodus  of  Americans 
to  foreign  water  resorts.  As  a  fact,  we  fear  the  fault  rests  with  the 
American  physician,  not  the  American  waters.  Few  native  physi- 
cians o-ive  to  the  selection  and  adaptation  of  proper  mineral  waters 
the  consideration  it  deserves  ;  whereas,  in  German,  French,  and 
English  practice,  this  forms  a  common  and  important  factor.  Ac- 
cording to  Baruch,  even  American  doctors  resident  at  the  springs 
do  not  insist  upon  precision  in  proper  drinking,  diet,  hydrotherapy, 
or  exercise. 

The  surpassing  virtues  of  our  American  mineral  waters  can  only 
be  attested  by  making  an  individualizing  selection  of  the  waters 
to  each  case,  after  establishing  the  diagnosis. 

Too  much  empiricism,  too  much  fashion  and  sport,  too  much 
abuse  of  alcohol,  and  not  sufficient  peace  and  quiet  of  mind  exhibit 
themselves  at  our  American  springs. 

Without  a  diagnosis — not  to  speak  of  test-meals — we  have  known 
of  numerous  instances  where  springs  were  ordered.  Systematic 
mineral-water  treatment  should  be  recommended  only  after  the 
institution  of  careful  chemical  and  physical  examinations. 

In  reference  to  the  abuse  of  mineral  waters,  we  will  limit  our- 
selves to  their  misuse  in  gastric  diseases.  We  would  exclude, 
first,  all  cases  of  motor  insufficiency  of.  any  kind,  whether  of  th 
simple  atonic  or  the  stenotic  form,  whether  with  pronounced  dilata 


e 


*In  the  preparation  of  this  chapter  we  have  availed  ourselves  of  the  Analyses  of  the 
Mineral  Springs  of  the  U.  S.  as  given  in  the  records  of  the  Department  of  the  Interior 
(Agriculture),  Washington,  D.  C.  ;  and  in  the  description  of  the  physiological  effects  of 
the  various  springs,  we  have  followed  the  works  of  Flechsig,  S.  Baruch,  Ludwig,  and 
G.  Thompson  in  reference  to  waters  with  which  we  have  no  personal  experience. 

300 


CONTRA-INDICATIONS    TO    THE    USE    OF    MINERAL    WATERS.       3OI 

tion  or  not,  because  we  know,  upon  very  good  authority  (von  Meh- 
ring,  loc.  cit),  that  water  is  not  absorbed  from  the  stomach,  and 
hence  can  only  aggravate  (by  its  weight)  the  myasthenia  and  dilata- 
tion. Where,  however,  the  various  saline  and  alkaline  waters  can 
be  readily  obtained,  they  serve  admirably  for  lavage.  The  sodium 
chlorid  spring  water  is  beneficial  in  sub-  or  anacidity,  and  the 
alkaline  waters  whenever  hyperchylia  is  associated  with  dilatation. 

In  neoplasms  of  the  stomach,  particularly  in  carcinoma,  mineral- 
water  treatment  is  harmful.  For  ulcer,  the  Carlsbad  springs  have 
been  much  lauded  by  Leube  and  others;  but  we  coincide  with 
Ewald's  opinion,  that  the  same  or  perhaps  more  rapid  effects  would 
have  been  obtained  in  such  cases  had  patients  taken  the  rest-cure 
at  home.  Rest,  diet,  and  effective  local  treatment  are  the  things 
most  needed,  and  these  can  be  obtained  much  more  readily  at  home 
than  elsewhere.  For,  after  all,  as  far  as  gastric  sufferers  are  con- 
cerned, the  most  important  things,  even  at  the  springs,  are  diet, 
suitable  food,  good  cooking,  etc. 

In  acute  gastritis,  mineral  waters  are  useless.  There  remain  still 
to  be  considered  the  neuroses  of  secretion  and  motility.  All  secre- 
tory neuroses  are,  more  or  less,  indications  for  mineral-water  treat- 
ment, particularly  those  in  which  an  excessive  amount  of  HCl  is 
formed,  with  which  the  alkaline  waters  combine,  at  the  same  time 
executing  a  very  desirable  astringent  effect  on  the  mucosa.  In 
achylia  of  nervous  origin,  the  saline  waters  might  rationally  be 
tried  ;  but  where  the  glandular  elements  are  destroyed  they  can  not 
restore  the  secretion,  although  they  may  aid  in  dissolving  mucus 
and  keeping  the  membrane  cleaner  than  otherwise.  In  the  motor 
neuroses,  if  dependent  on  hyperchylia  or  hypersecretion,  the 
alkaline  waters  may  benefit  by  removing  the  causes,  as  stated 
above.  But  in  insufficiency  of  the  pylorus  and  cardia  we  have 
neither  heard  of  nor  seen  improvement. 

The  proper  field  for  these  waters  is  undoubtedly  chronic  gas- 
tritis. With  their  judicious  use  much  good  can  be  effected.  It 
should  not  be  overlooked,  however,  that  there  may  be  a  chronic 
gastritis  with  normal  or  excessive  acidity;  here  the  alkaline  waters 
are  to  be  preferred  to  the  salines — sodium  chlorid.  In  chronic 
gastritis  with  achylia,  only  salines  of  a  mild  concentration  are 
useful ;  for  the  powerful  saline  (NaCl)  waters,  such  as  Carlsbad 
(Miihlbrunnen),  may  undoubtedly  cause  an  injurious,  alkaline, 
irritative  transudate  from  the  mucosa  if  retained  in  the  stomach. 


302  MINERAL   SPRINGS. 

Ewald  [loc.  cit.)  says :  "  The  saline  waters  are  indicated  in 
all  cases  of  catarrh  with  lessening  of  secretion,  either  with  or  with- 
out the  production  of  mucus.  Here  we  may  use  the  simple 
sodium  chlorid  waters  where  the  patient  is  otherwise  well,  and 
only  the  gastric  and  intestinal  secretions  are  to  be  augmented  ;  the 
sparkling  sodium  chlorid  waters  are  useful  where  we  desire  the 
stimulating  effects  of  the  carbonic  acid  gas,  and  where,  by  moderate 
catharsis  and  the  use  of  the  brine  as  such,  the  metabolism  may  be 
increased.  Finally,  all  waters  which  are  to  act  on  the  stomach  are 
borne  better  warm  than  cold. 

"  On  the  other  hand,  experience  has  shown  that  the  alkaline-saline 
and  the  alkaline  springs  are  very  beneficial  in  conditions  of  hyper- 
acidity or  hypersecretion.  The  successful  use  of  Carlsbad  water 
in  ulcer  of  the  stomach  is  now  much  more  readily  understood, 
since  we  know  that  the  ulcer  is  in  many  cases  accompanied  by 
hyperacidity,  and  that  the  mineral  water  not  alone  momentarily 
neutralizes  this  (just  as  in  cases  of  hypersecretion),  but  also  that 
it  may  actually  lessen  the  activity  of  the  secretion.  A  similar 
effect  might  also  be  produced  by  the  purely  alkaline  waters,  but 
they  have  not  yet  been  much  used  for  this  purpose.  Finally,  the 
sodium  sulphate  waters  are  to  be  used  in  those  cases  in  which  the 
stomach  is  only  secondarily  involved  from  disturbances  of  the 
liver  and  intestines." 

According  to  Stille  and  Maisch,  there  are,  indeed,  two  classes  of 
patients  who  require  the  use  of  very  different  mineral  waters.  The 
first  is  composed  of  that  large  body  of  invalids  in  whom  there  exists 
no  organic  change  of  structure,  but  whose  functions  are  merely 
weakened  or  clogged  by  the  strain  of  business,  the  exhaustion  of 
pleasure,  sensual  excesses  in  eating  or  drinking,  or,  in  this  country 
especially,  by  the  manifold  errors  committed  in  the  preparation 
and  consumption  of  food  and  the  disregard  of  hygienic  rules  in 
their  habits  of  living.  The  second  consists  of  that  smaller  but 
still  numerous  class  of  persons  who,  besides  being  more  or  less 
injured  by  the  causes  of  ill  health  just  enumerated,  have  been 
affected  with  definite  diseases,  and  especially  rheumatism,  gout, 
calculous  disorders,  cutaneous  eruptions,  scrofula,  syphilis,  diabe- 
tes, paralysis,  uterine  disorders,  etc.  Of  these  two  classes,  the 
former  is  benefited  most  by  a  visit  to  the  less  mineralized  springs, 
while  the  latter  requires  a  course  of  active  medicinal  treatment 
such   as   the   stronger  mineral  waters  afford.     In  both  classes  of 


INDICATIONS    FOR    THE    USE    OF    MINERAL    WATERS.  3O3 

patients,  but  particularly  in  the  first,  the  action  of  the  waters  is 
only  one  out  of  many  influences  that  combine  to  restore  their 
health.  Toward  that  end  a  total  change  of  habits  is  one  of  the 
most  influential  agencies  in  very  many  cases.  Escape  from  the 
anxieties  and  fatigue  of  business,  from  the  excitement  of  fashion- 
able life,  the  mental  tension  of  political  and  professional  pursuits, 
the  worrying  annoyances  of  domestic  affairs,  endured,  perhaps,  in 
a  large  city,  with  all  its  enervating  social  duties,  its  Babel-like 
sounds,  and  its  polluted  atmosphere, — escape  from  these  alone 
ought  to  suffice  to  restore  the  disturbed  balance  of  health.  When 
we  consider  how  much  more  probable  must  this  result  become 
when  fatigue,  anxiety,  contention,  wearisome  routine,  and  foul  air 
are  exchanged  for  repose  and  peace  in  the  midst  of  novel  scenes 
and  new  associates,  and  freedom  from  the  onerous  conventionali- 
ties of  fashionable  life,  different  apartments,  food,  and  occupation, 
it  may  even  seem  doubtful  whether,  after  all,  some  other  new  resi- 
dence would  not  profit  the  invalid  as  much  as  the  frequented 
springs.  But  there  are  two  reasons  against  this  conclusion  :  the 
one  is  that,  with  many  persons,  relief  would  be  impossible  without 
an  exercise  of  the  faith  which  gives  potency  to  waters  as  well  as  to 
other  remedial  agents  ;  and  the  other  is  that  even  the  purest  of 
these  waters,  systematically  used,  especially  in  conjunction  with 
bathing  and  regular  exercise,  do,  in  a  greater  or  less  degree,  depu- 
rate the  system  through  the  kidneys,  bowels,  and  skin,  and  by  a 
gentle  but  sustained  action  gradually  remove  effete  products  of 
tissue  change  from  the  system  and  free  the  organs  from  the 
poisons  that  tainted  them.  Judiciously  used  under  the  advice  of  a 
competent  physician,  these  almost  neutral  waters  and  the  milder 
saline  springs  are  capable,  in  a  few  weeks,  of  changing  the  languid, 
indifferent,  pale,  and  feeble  invalid  into  the  lively  and  energetic 
leader  of  the  gay  crowd.  Such  rapid  transformations  are  frequently 
witnessed,  especially  at  the  hot  springs  of  Virginia,  the  Bedford 
Springs,  Pa.,  at  some  of  the  Saratoga  Springs  (though  in  the  last- 
mentioned  place  routine  hygienic  treatment  becomes  more  difficult 
because  of  numerous  side  temptations),  and  certain  European 
springs,  such  as  Wildbad,  Gastein,  and  Pfefifers,  none  of  which 
contains  any  considerable  proportion  of  mineral  ingredients.  But 
these  waters,  whether  drunk  warm  or  cold,  if  they  are  largely 
used,  act  as  organic  purgatives,  and  increase  materially  the  total 
amounts  of  solids,  and  especially  of  urea,  excreted  with  the  urine. 


304  MINERAL    SPRINGS. 

without  causing  the  debility  which  an  equal  discharge  from  the 
bowels  would  occasion. 

Alkaline  Waters. — The  chief  ingredients  of  these  waters  are 
the  alkaline  carbonates,  especially  the  carbonate  of  sodium.  They 
also  contain  varying  amounts  of  the  carbonates  of  lime,  mag- 
nesium, lithium,  sodium  chlorid,  etc.,  and  many  of  them  are 
strongly  charged  with  carbonic  acid  gas.  Although  it  is  probable 
that  the  other  saline  constituents  may  contribute  to  the  total  phys- 
iological effects  of  these  waters,  they  owe  their  main  therapeutic 
activity  to  the  alkaline  salts  they  contain.  The  temperature  of 
these  springs  is  also  a  point  worthy  of  consideration.  In  a  general 
way,  it  may  be  said  that  the  physiological  action  of  these  waters  is 
like  that  of  any  alkaline  salt,  plus  the  effect  produced  by  the  circu- 
lation of  large  quantities  of  water  in  the  system.  The  carbonate 
of  sodium  neutralizes  free  acids  or  fermentation  products  in  the 
stomach,  whether  taken  during  or  after  meals.  According  to 
Brunton  and  Sidney  Ringer,  the  stronger  alkaline  waters,  if  taken 
before  meals,  increase  the  secretion  of  gastric  juice.  The  fact  is, 
plain,  distilled  water  will  also  cause  a  secretion  of  gastric  juice  in 
the  normal  stomach.  The  carbonic  acid  set  free  by  the  decom- 
position of  the  carbonates  in  the  stomach,  and  the  sodium  chlorid 
usually  present  in  these  waters,  act  as  a  stimulant  to  the  gastric 
mucous  membrane,  promoting  secretion  and  counteracting  any 
disturbing  influence  exerted  by  the  carbonate.  The  free  carbonic 
acid  frequently  contained  in  waters  of  this  class,  by  its  stimulating 
effects  on  gastric  peristalsis,  accelerates  digestion,  and  thereby 
increases  the  desire  for  food. 

It  would  appear,  therefore,  that  the  alkaline  waters  have  a  wide 
range  of  usefulness.  They  seem  to  be  especially  indicated  in 
gastric  affections  in  which  there  is  an  excessive  production  of 
hydrochloric  acid,  as  in  acid  dyspepsia,  atony  of  the  gastric 
mucous  membrane,  and  gastric  ulcer.  In  all  catarrhal  conditions 
of  the  stomach  they  are  most  serviceable,  but  a  free  and  prolonged 
use  lowers  the  nutrition,  except  in  case  of  waters  containing 
chlorid  of  sodium. 

The  names  of  a  few  of  the  more  important  Alkaline  Waters 
are  here  appended  : 

Vichy,  in  France;  Ems  and  Fachingen,  in  Germany;  Saratoga 
Vichy  (rich  in  CO2),  New  York  ;  St.  Louis  Springs,  Michigan 
(poor    in    CO2) ;     Bethesda    Springs,    Wisconsin.      Other    sodium 


ALKALINE    AND    ALKALINE    SULPHUR    WATERS.  305 

chlorid  waters,  containing  also  some  carbonates  and  CO,,  are  : 
Hathorn,  Congress,  and  Kissengen  Springs,  in  Saratoga,  New  York  ; 
Homburg,  Wiesbaden,  Kissingen,  and  Selters,  in  Germany  ;  Bour- 
bonne,  in  France. 

All  alkaline  waters  contain  more  or  less  carbon  dioxid,  and 
their  most  important  ingredients  are  the  alkaline  carbonates. 
They  also  contain  sodium  chlorid,  and  sometimes  sodium  sulphate. 
In  some,  one  variety  of  salts,  in  others,  another  preponderates. 
Generally  speaking,  the  European  waters  are  richer  in  alkalies 
than  are  the  American. 

Alkaline  waters  are  useful  in  uric  acid  diathesis  and  lithemic 
conditions,  gout,  chronic  rheumatism,  obesity,  hepatic  engorgement, 
gall-stones,  hyperacidity,  gastric  ulcer,  and  catarrhs  of  the  mucous 
i^embranes,  especially  of  the  stomach,  respiratory  tract,  and 
bladder. 

Alkaline  Sulphur  "Waters. —  Richfield  Springs,  Sharon  Springs, 
and  Avon  Springs,  in  New  York;  Greenbrier  White  Sulphur 
Springs,  in  West  Virginia;  Harrogate,  in  England;  Neuen- 
dorf and  Meinberg,  in  Germany ;  Aix-la-Chapelle,  in  Rhenish 
Prussia. 

Those  waters  containing  sulphuretted  hydrogen  in  addition  to 
other  ingredients  are  used  moderately  in  gout,  chronic  rheumatism, 
obesity,  and  chronic  eczema.  They  are  often  supplemented  by  a 
course  of  chalybeate  waters. 

Alkaline  and  saline  purges  contain  a  high  percentage  of  sodium 
and  magnesium  sulphates.  These  waters  are  often  called  "bitter 
waters."  Such  are  Pijllna,  in  Bohemia  (the  strongest  of  all  and 
one  of  the  oldest  known);  Carlsbad  (Sprudel),  in  Bohemia;  Marien- 
bad  (Kreuzbrunnen),  in  Bohemia;  Friedrichshall,  in  Germany; 
Franz  Josef,  in  Austria;  Kissingen  Bitterwater,  in  Bavaria;  Hun- 
yadi  Janos,  in  Hungary  ;  Rubinat  Condal  Spring  and  Villacabras, 
in  Spain  ;  Crab  Orchard  and  Estill  Springs,  in  Kentucky  ;  Bedford 
Springs,  in  Pennsylvania;  Epsom,  in  England;  some  of  the  Sara- 
toga waters.  These  waters  are  useful  to  counteract  indiscretions 
in  diet  and  congestion  of  the  liver.  The  Rubinat  water  is  effective 
and  possesses  the  advantage  of  being  less  disagreeable  than  many 
of  the  others.  Villacabras  water  is  a  Spanish  sodium  sulphate, 
strongly  purgative  water,  obtained  not  far  from  Madrid. 

These  waters  should  be  taken  either  very  cold  or  in  a  half-pint  of 
very  hot  water.     If  drunk  lukewarm  their  taste  is  nauseous  and  may 


3o6 


MINERAL   SPRINGS. 


excite  emesis.  We  advise  that  these  powerful  waters  be  entirely 
avoided  where  there  is  any  distinct  organic  disease  of  the  stomach. 

Chalybeate  Waters. — Schwalbach  (Stahlbrunnen),  Pyrmont 
(Neubrunnen),  Spa,  Belgium  ;  St.  Moritz,  Switzerland  ;  Rock  Enon, 
Virginia.  These  waters  are  claimed  to  serve  as  tonics  for  the  blood 
and  nerves,  but  if  used  too  long  they  cause  dyspepsia  and  anemia. 
There  is  no  evidence  that  there  is  any  increase  of  red  blood-cor- 
puscles by  the  use  of  these  waters  exclusively ;  whatever  improve- 
ment follows  is  due  to  the  diet  and  the  hygienic  environment. 

Acidulous  "Waters. — These  waters  contain  CO2  in  excess,  and 
but  very  little  salts  of  any  kind.  Such  are  Clysmic  Spring,  in  Wis- 
consin; Blue  Lick,  in  Kentucky;  Carlsbad  (Dorotheenquelle),  in 
Bohemia. 

Various  other  tvaters  are  the  Alum  Springs,  in  Virginia ;  Oak 
Orchard  Acid  Spring,  in  New  York;  Bourboule,  in  France,  which 
contains  arsenic.  Roncegno  water  is  a  ferruginous  arsenical  water 
from  the  Tyrolean  province  of  Trent. 

COMPARATIVE  CHART  ILLUSTRATIVE  OF  ALKALINE  WATERS.— 

i^Baruch.') 


Ojo  Caliente  Spring. 
New  Mexico,    . 


Vichy  (Grand 
Grible  Spring), 
France,      .    .    . 


One  Pint  Contains: 


Fachingen  Spring, 
Germany,      .    . 


Saratoga  Viciiy 
Spring,  NewYork, 


St.    Louis   Spring, 
Michigan,  .    .    . 


Ems  (Kesselbrun- 
nen  Spring), 
Germany,      .    . 


Grs. 


26 


14 
19 


Cub.  in. 


14 


Fahr. 
105.8° 

100° 

50° 

50° 

6     I   115° 
I     ,     50° 


Other  Prominent  Con- 
stituents. 


Sodium  chlorid,  4  grs.; 

sodium     sulphate,     2 

grs. ;    potassium    car- 
bonate, 2  grs. 
Sodium  chlorid,  4  grs.; 

sodium  sulphate,  I  gr. 
Sodium  chlorid,  4  grs.; 

calcium   carbonate,    2 

grs. 
Calcium  and  magnesium 

carbonates,     17    grs.; 

sodium  and  potassium 

chlorids,  18  grs. 
Sodium  chlorid,  7  grs. ; 

calcium    carbonate,   I 

gr. 
Calcium  and  magnesium 

carbonates,     6     grs. ; 

calcium    sulphate,    7 

grs. 


SODIUM    CHLORID    AND    BITTER    WATERS.  3O7 

Saline  Waters. — This  class  may  be  conveniently  subdivided 
into,  first,  waters  containing  chiefly  the  chlorid  of  sodium  ;  and, 
second,  waters  containing  large  quantities  of  the  sulphates  of 
sodium  and  magnesium — the  so-called  "  bitter  waters  "  of  German 
authors. 

The  Sodium  Chlorid  \A(^aters. — These  waters  contain,  besides 
large  quantities  of  sodium  chlorid,  a  certain  proportion  of  other 
chlorids,  especially  those  of  lime  and  magnesium,  and  small 
amounts  of  alkaline  and  earthy  sulphates  and  carbonates,  iodids  and 
bromids.  Carbonate  of  iron  is  sometimes  present  in  considerable 
quantity.  The  gases  consist  for  the  most  part  of  carbonic  acid, 
which  renders  the  water  more  agreeable  to  the  palate  and  more 
readily  absorbed.  Some  of  these  waters  are  heavily  charged  with 
sulphuretted  h37drogen.  They  occur  both  as  cold  and  thermal 
springs,  and  may  be  utilized  both  for  drinking  and  bathing  purposes. 

The  physiological  action  of  these  waters  is  chiefly  attributable  to 
the  presence  of  sodium  chlorid.  This  salt,  as  is  well  known,  has 
a  stimulating  effect  upon  all  the  mucous  membranes  of  the  body, 
especially  that  of  the  gastro-intestinal  tract.  In  the  stomach  it 
dissolves  the  mucus,  increases  the  secretion  of  gastric  juice,  pro- 
motes the  digestion  of  albuminous  substances,  and  excites  peris- 
talsis. In  the  intestines  it  stimulates  the  flow  of  pancreatic  juice 
and  bile,  and,  owing  to  its  well-known  influence  on  the  process  of 
osmosis,  promotes  the  absorption  of  food.  Intestinal  peristalsis  is 
also  increased,  and,  if  the  sodium  chlorid  is  present  in  large 
quantity,  the  water  may,  in  its  effects,  be  laxative  and  even  purga- 
tive. Some  authors  have  regarded  this  purgative  action  as  repre- 
senting the  chief  therapeutic  virtues  of  these  waters,  but,  according 
to  Flechsig,  it  is  subordinate  in  importance  to  the  effect  of  the 
sodium  chlorid  on  the  blood.  He  states  that  this  salt  exerts 
considerable  influence  on  the  process  of  tissue  metabolism,  aug- 
menting the  metamorphosis  of  nitrogenous  matters  and  increasing 
the  oxidation  of  albuminous  substances,  as  is  shown  by  the 
increased  quantity  of  solids  in  the  urine.  The  iodids  and  bro- 
mids contained  in  some  of  these  waters  are  usually  present  in 
such  very  minute  amounts  that  it  is  doubtful  whether  they  con- 
tribute to  their  therapeutic  action  ;  at  any  rate,  it  is  impossible  to 
separate  their  effects  from  those  of  the  sodium  chlorid. 

The  therapeutic  indications  of  sodium  chlorid  waters,  as  based 
upon   their  physiological    action,  are  sufficiently   obvious.     Their 


3o8 


MINERAL    SPRINGS. 


stimulating  effects  upon  the  mucous  membranes  have  been  utilized 
in  the  treatment  of  catarrhal  processes,  especially  in  the  stomach, 
duodenum,  and  bile-ducts ;  and  in  chronic  intestinal  catarrh  asso- 
ciated with  constipation,  their   use  has  been   highly  commended. 


COMPARATIVE    CHART    ILLUSTRATIVE    OF    SALINE 
WATERS.— (^^;w//.) 


European. 


One  Pint  Contains  : 


•-  a 


(U  <-• 


Other  Prominent  Constituents. 


B  a  1 1  s  t  o  n  Artesian 
Lithia  Well,  New 
York, 


Homburg  (Elizabeih- 
brunnen),  Ger- 
many,     


Plathorn  Spring,  Sar- 
atoga, New  York, 


Wiesbaden  (Koch- 
br  u  n  ne  n  ),  Ger- 
many,    ..... 


Congress  Spring, 
Saratoga,  New 
York, 


Bourbonne  (Fontaine 
Chaude) ,   France, 


Kissengen  Spring, 
Saratoga,  New 
York, 


Kissingen  (Rakoczi), 
Germany,      .    .    . 


Saratoga     Seltzer 
Spring,  New  York, 


Selters,    Germany, 


Grs. 

79 
93 

52 
64 
46 

50 

44 

42 

17 
17 


Cub. 


53 

17 

47 

49 
42 

45 
30 


Fahr. 


50° 


155° 

47° 
149°  j 

52°, 

5x°l 


Grains. 


Chlorids  of  calcium  and 
magnesium,  15;  cal- 
cium carbonate,  II. 

Magnesium  and  calcium 
carbonate,  34 ;  potas- 
sium chlorid,  4 ;  lithium 
carbonate,  0.7. 

Chlorid  of  potassium,  l ; 
calcium  carbonate,  3. 

Calcium  and  magnesium 
carbonates,  28. 

Calcium  chlorid,  5  ;  cal- 
cium sulphate,  6. 

Calcium  and  magnesium 
carbonates,  21  ;  sodium 
bromid,  i  06. 

Potassium  chlorid,  2  ;  cal- 
cium carbonate,  8. 


40°:  Calcium  and  magnesium 
carbonates,  26  ;  sodium 
carbonate,  8 ;  lithium 
carbonate,  o  64. 

62°,  Sodium  carbonate,  6. 

50°  Sodium  carbonate,  2  ;  cal- 
cium and  magnesium 
carbonates,  10. 


Bitter  or  Purgative  ^A^aters. — This  name  has  been  applied  to 
waters  characterized  by  a  high  percentage  of  the  sulphates  of 
sodium  and  magnesium.  They  also  contain  considerable  quanti- 
ties of  the  sulphates  of  lime,  and  the  carbonates  of  lime  and  mag- 
nesium, though  rarely  small  amounts  of  carbonic  acid  gas. 
Carbonate  of  sodium,  however,  is  seldom,  if  ever,  found  in  them. 


BITTER    OR    PURGATIVE    WATERS. 


309 


The  chief  physiological  action  of  these  waters  is  comprised  in 
the  stimulating  effect  which  they  exert  upon  the  mucous  mem- 
branes of  the  gastro-intestinal  tract.  They  give  rise  to  a  pro- 
fuse watery  secretion  of  a  serous,  or  even  mucous,  character,  and 
thus  act  as  purgatives.  If  taken  in  large  quantities,  they  fre- 
quently   produce    gastric    and    intestinal    disturbances,    and    their 


COMPARATIVE  CHART  ILLUSTRATIVE  OF  BITTER  WATERS. —{Banic/i  ) 


American. 


Crab  Orchard, 
Foley's  Spring, 
Kentucky,    .    . 


European. 


Grs. 
Piillna,  Bohemia,'    124 


Estill's  Springs, 
Irvine  Springs, 
Kentucky,    .    . 


Friedrichshall, 
Germany,  . 


Bedford  Springs, 
Pennsylvania, 


Harrodsburg 
Spring,  Saloon 
Spring,  Ken- 
tucky, .    .    .    . 


Carlsbad  (Spru- 
del), Bohemia, 


bs 


41 


19 


Marienbad 
(Kreutzbrunnen), 
Bohemia,    .    .        36 


One  Pint  Contains  : 


Grs. 

93 

25 
39 

32 


28 


CJ<; 


Cub.  in, 


Fahr. 


46° 


8  ^   162° 

9  58° 
15     I     53° 


Other  Prominent 
Constituents. 


Chlorid  of  magne- 
sium, 16  grs. ;  mag- 
nesium carbonate, 
6  grs. 

Calcic  carbonate,  7 
grs. ;  potassium  sul- 
phate, I  gr. 

Sodium  chlorid,  67 
grs.;  magnesium 
chlorid,  31  grs.; 
calcic  sulphate,  II 
grs. 

Calcic  carbonate,  4 
grs.;  sodium  chlo- 
rid, 2  grs. 

Sodium  carbonate,  9 
grs.;  sodium  chlo- 
rid, 8  grs. 

Chlorid  of  sodium,  i 
gr.;  calcium  sul- 
phate, 2  grs. 

Sodium  carbonate,  8 
grs.;  sodium  chlo- 
rid, II  grs. 

Calcic  sulphate,  10 
grs.;  sociium  chlo- 
rid, I  gr. 


protracted  use  is  apt  to  be  followed  by  atony  of  the  intestines  and 
intestinal  catarrh.  It  is  as  yet  a  matter  of  speculation  whether 
this  purgative  action  is  due  to  the  increased  exudation  of  fluids,  or 
whether  it  results  from  the  stimulation  of  intestinal  peristalsis,  as 
is  assumed  by  Flechsig  and  others.  Owing  to  the  increased  peris- 
talsis, the  passage  of  food  through  the  intestines   is  accelerated ; 


310  MINERAL   SPRINGS. 

and  in  consequence  of  the  diminished  absorption  of  nutriments 
engendered  b}-  this,  a  loss  of  weight  and  disappearance  of  the  fatty 
tissue  results. 

It  follows  from  the  above  considerations  that  the  use  of  these 
waters  is  restricted  to  cases  in  which  we  desire  to  stimulate  the 
intestinal  secretions,  as  in  chronic  constipation  occurring  in  ple- 
thoric persons,  engorgements  of  the  abdominal  and  pelvic  viscera, 
hemorrhoids,  etc.  They  also  prove  serviceable  in  cases  of  obesity, 
as  part  of  a  treatment  of  denutrition.  On  the  other  hand,  their 
use  is  contra-indicated  in  anemic  persons,  and  where  there  is  great 
irritability  of  the  stomach  and  intestines,  with  a  tendency  to 
diarrhea. 

American  waters  of  this  class  are  somewhat  weaker  in  sulphates 
of  sodium  and  magnesium  than  the  European,  but  the  quantity  of 
purgative  salts  present  in  the  former  is  quite  sufficient  to  produce 
active  therapeutic  effects.  All  these  waters  contain  a  considerable 
amount  of  sodium  chlorid,  which  contributes  essentially  to  their 
physiological  action. 

The  Bedford  Spring  (Pa.)  water  is  especially  to  be  recommended 
on  account  of  its  mildness.  It  is,  in  our  opinion,  of  no  advantage 
when  spring  waters  possess  an  excessively  large  percentage  of 
drastic  salts.  In  a  concentrated  solution  magnesium  chlorid  acts 
as  a  cellular  poison  on  the  superficial  gastric  and  intestinal  epithe- 
lium when  used  for  weeks.  Bedford  Mineral  iNIagnesia  Spring  has 
also  a  mildly  diuretic  effect ;  its  laxative  effect  is  not  experienced 
until  at  least  500  c.c.  are  taken  in  twelve  hours. 

Sulphuretted  Waters. — The  constituent  imparting  to  these 
waters  their  distinguishing  characteristic  is  the  sulphuretted  hydro- 
gen which  they  contain  in  greater  or  lesser  amount.  With  this 
gas  we  find  associated  a  varying  quantity  of  sulphur  combinations, 
such  as  the  sulphids  of  potassium,  sodium,  calcium,  and  magne- 
sium. They  also  contain  the  alkaline  and  earthy  sulphates  and 
carbonates,  the  chlorid  of  sodium,  and  the  sulphates  and  carbonates 
of  iron  ;  and  these  are  frequently  present  in  large  quantities,  and 
certainly  play  a  not  unimportant  part  in  the  therapeutic  action  of 
these  waters.  According  to  Daland,  "  a  sulphur  spring  of  moder- 
ate strength  contains  not  less  than  12  cubic  inches  of  sulphuretted 
hydrogen  in  the  gallon,  though  many  springs  contain  so  small  an 
amount  that  therapeutically  they  are  inert,  and  the  good  effects 
observed  are  due  to  the  influence  of  the  increased  use  of  water, 


f 


SULPHURETTED    WATERS.  3II 

change  of  scene  and  climate,  cessation  of  work,  regular  meals,  good 
hygiene,  and  hope, — all  of  which  contribute  strongly  to  restore 
health  at  all  springs."  Many  of  the  sulphur  waters  are  thermal, 
and  are  chiefly  employed  in  baths. 

Regarding  the  physiological  action  of  sulphur  waters  on  the 
system,  nothing  positive  can  be  said.  Various  plausible  theories 
have  been  proposed  to  account  for  their  curative  effects  in  the 
diseases  for  which  they  are  employed.  It  is  claimed  that  their 
chief  action  is  exerted  on  the  intestinal  canal,  where  they  stimulate 
the  functions  of  the  glands,  augmenting  secretion  and  producing 
laxative  effects.  When  administered  for  prolonged  periods,  they 
give  rise  to  gastro-intestinal  disorders  and  exert  a  debilitating 
influence  upon  the  blood,  heart,  and  lungs,  as  evidenced  by  anemia, 
cardiac  weakness,  etc.  According  to  Leichtenstern,  the  sulphuretted 
hydrogen  absorbed  into  the  blood  is  rapidly  converted  into  sul- 
phuric acid,  and  is  therefore  devoid  of  any  specific  effect,  unless 
present  in  very  large  amounts.  On  the  other  hand,  Stifft  concludes 
that  the  sulphuretted  hydrogen  has  a  specific  excitant  action  upon 
the  sensitive  fibers  of  the  pulmonary  branches  of  the  pneumogas- 
tric  and  upon  the  respiratory,  cardiac,  and  vasomotor  centers,  its 
prolonged  use  giving  rise  to  paralysis  from  overstimulation.  In 
this  way  he  explains  the  action  of  the  sulphur  waters  upon  the 
respiratory  and  circulatory  systems,  upon  tissue-metabolism,  and 
upon  the  secretory  and  excretory  functions. 

These  waters  have  been  administered  internally  in  passive  con- 
gestion of  the  abdominal  and  pelvic  viscera,  especially  in  plethoric 
persons;  in  enlargements  of  the  liver  and  spleen;  hemorrhoids; 
chronic  intestinal  catarrh  ;  and  chronic  poisoning  by  metals.  In  the 
form  of  baths  they  have  been  recommended  in  gout  and  chronic 
rheumatism,  but  their  curative  effect  in  these  cases  is  attributable 
to  the  elevated  temperature  of  the  waters  rather  than  to  any 
specific  action  of  the  sulphuretted  hydrogen  or  other  constituents. 
At  many  baths  the  internal  or  local  use  of  the  waters  is  combined 
with  inhalation  of  the  gases  or  of  the  nebulized  waters;  and  this 
method  has  been  found  useful  in  the  treatment  of  chronic  catarrhs 
of  the  pharynx,  larynx,  and  bronchi.  Sulphuretted  waters  are,  in 
our  estimation,  worthless  as  a  therapeutic  agent  in  gastro-intestinal 
diseases. 

The  following  chart  illustrates  the  superiority  of  the  sulphur 
waters  of  America: 


312 


MINERAL   SPRINGS. 


COMPARATIVE    CHART    ILLUSTRATIVE    OF   SULPHURETTED 
WATERS.  — {Banic/i.) 


One  Pint  Contains  : 


European. 


Sandwich  Spring, On- 
tario, Canada,   .    . 


Sharon  Spring,  White 
Sulphur  Spring, 
New  York,  .    .    . 


Paroquet     Spring 
Kentucky,     .    .    . 


Salt  Sulphur  Spring, 
lodin  Spring,  W. 
Virginia,    .... 


,5S 


Cub. 


Grs. 


Neundorf,  Germany,;  1. 28  io.55 
i  472  I    .    . 


Aix-le-Bains. 
France,      .    .    . 


Harrogate,        Eng. 
land,      


Meinberg,  Germany, 


053 


3-75 
0.61 


2-39 


0.28 


1-54 


0.67 


u      :  Other  Prominent  Constituents. 


53°  Calcium  and  magnesium 
sulphates,  10  grs. 

52°  Chlorid  of  magnesium,  19 
grs.  ;    calcium  sulphate, 

Calcium  carbonate,  I  gr. 


Calcium  and  magnesium 
sulphates,  24  grs. 

Sodium  chlorid,  86  grs.  ; 
potassium  and  magne- 
sium chlorids,  10  grs. 

Sodium  chlorid,  39  grs. 

Sodium  sulphate,  6  grs. 


Sodium  sulphate,    3  grs. ; 
calcium  sulphate,  8  grs. 


Chalybeate  Waters. — A  large  number  of  mineral  springs  con- 
tain the  salts  of  iron,  but  the  quantity  present  is  frequently  so 
small  as  to  be  practically  devoid  of  therapeutic  effects.  In  the 
class  under  consideration  only  waters  containing  a  sufficient  quan- 
tity of  chalybeates  to  be  of  value  in  the  treatment  of  disease  will 
be  mentioned. 

Iron  salts  usually  occur  in  the  form  of  the  carbonate  or  sulphate. 
Other  constituents,  which  are  sometimes  present  in  large  amounts, 
are  the  alkaline  carbonates  and  sulphates,  the  earthy  carbonates, 
sodium  chlorid,  alum,  and  sulphuric  acid.  Alum  often  exists  in 
considerable  quantities,  especially  in  the  chalybeate  springs  of 
Virginia. 

Chalybeate  waters  containing  the  carbonate  of  iron  are  clear, 
odorless,  have  a  slight  inky  taste,  and  are  highly  charged  with 
carbonic  acid  gas,  which  renders  them  palatable.  They  are  chiefly 
employed   for    drinking    purposes.       The    sulphate-of-iron    waters 


CHALYBEATE    WATERS. 


313 


have  a  marked  astringent  taste,  which  sometimes  proves  an  objec- 
tion to  their  use.  This  astringency  may  be  decidedly  increased  by 
the  presence  of  alum. 

The  following  chart   illustrates   the   superior   quality   of   some 
American  chalybeate  springs  : 

CHALYBEATE  WATERS.— {Banec/i.) 


One  Pint  Contains  : 


=  2 
o  J5 


Oiher  Prominent  Constituents. 


u<: 


Church    Hill    Alum 
Springs,  Virginia, 


Rock  Enon  Springs, 
Virginia,    .... 


Brighton,    England,     1.80 
19.8 


Spa    (Buhon),    Bel- 
gium,      


Calcium  sulphate,  4  grs. 

Magnesium  and  calcium 
sulphates,  22  grs.  ;  alu- 
minium sulphate,  9  grs. 

0.67    71.6    Small  amounts  of  calcium 
carbonate  and  alumina. 


1.78 


Schwalbach    (Stahl- 
brunnen),      G  e  r- 


0.46 


Calcium  and  magnesium 
sulphates,  2  grs.  ;  cal- 
cium and  sodium  carbon- 
ates, alumina. 


50.2  Calcium  carbonate,  I  gr.  ; 
manganese  carbonate 
o.  10  gr. 


Vichy  Springs,  New 
Almaden,  Cal.,     . 


St.  Moritz  (Grande 
Source),  Switzer- 
land,     .    .    .    .    • 


o.6oi  29.8  Sodium  carbonate,  17  grs.; 
calcium  carbonate, 3  grs.; 
magnesium  sulphate,  i 
gr. ;  sodium  chlorid,  4 
ffrs. 


0.17 


39.2    Sodium  carbonate,  I  gr.  ; 
■     calcium      carbonate,     6 
grs.  ;   sodium    sulphate, 
I  £rr. 


Estill  Springs.  Ken- 
tucky,     


0.23  .4.15    Calcium  carbonate,  i  gr.  ; 
magnesium    sulphate,    I 


The  physiological  action  of  chalybeate  waters  is  essentially 
similar  to  that  of  all  iron  compounds;  they  promote  constructive 
metamorphosis,  increasing  the  number  of  red  corpuscles  in  the 
blood  and  stimulating  all  the  body  functions.  For  internal  use 
the  waters  containing  the  carbonate  of  iron  are  preferable,  since 
21 


314  MINERAL    SPRINGS. 

they  are  less  apt  to  disturb  the  stomach  and  are  more  easily  assimi- 
lated, owing  to  the  carbonic  acid  gas  present.  According  to  the 
character  of  the  case,  it  may  be  necessary  to  select  an  iron  water 
containing  alkalies,  sodium  chlorid,  sulphate  of  sodium  and  mag- 
nesia, or  alum. 

The  chalybeate  waters  have  been  recommended  in  anemia, 
chlorosis,  and  all  conditions  attended  with  anemia,  such  as  hysteria 
and  neurasthenia;  chronic  endometritis,  dysmenorrhea,  amenor- 
rhea, chronic  gonorrhea,  and  spermatorrhea;  chronic  affections  of 
the  kidneys,  diabetes  mellitus,  chronic  gastritis,  nervous  dyspepsia, 
chronic  diarrhea,  etc. 

Among  the  iron  and  alum  springs,  Bedford  Alum  Spring  has  been 
found  remarkably  efficacious  by  Baruch  in  chronic  diarrhea,  which 
had  resisted  both  private  and  hospital  treatment. 

The  contraindications  to  their  use,  as  given  by  Flechsig,  com- 
prise all  febrile  and  congestive  conditions  and  advanced  organic 
diseases  of  the  lungs,  liver,  and  kidneys.  The  sulphate-of-iron 
waters  are  excellent  astringents  and  disinfectants,  and  have  been 
highly  recommended  in  chronic  diarrhea,  gastric  ulcer,  etc. 

Acidulous  Waters. — These  waters  owe  their  therapeutic  prop- 
erties to  the  large  quantity  of  carbonic  acid  gas  they  contain,  the 
solid  constituents  being  present  only  in  small  amounts.  As  has 
been  stated,  many  alkaline  and  saline  waters  contain  considerable 
quantities  of  CO2 ;  but  its  effects,  whatever  they  may  be,  are  com- 
pletely subdued  by  those  of  the  mineral  ingredients.  In  the  acid- 
ulous waters,  however,  the  carbon  dioxid  is  the  chief  therapeutic 
agent,  and  for  this  reason  it  becomes  necessary  to  discuss  them 
as  a  separate  class  of  mineral  waters. 

The  physiological  action  of  carbonated  waters  is  comprised  in  a 
gentle  stimulative  effect  upon  the  mucous  membrane  of  the  stom- 
ach, promoting  peristalsis  and  thereby  a  more  rapid  evacuation  ot 
its  contents.  The  pulse  and  respiration  are  said  to  be  slightly 
accelerated,  and  a  large  quantity  of  urine  is  excreted.  It  seems, 
however,  that  this  diuretic  effect  is  not  attributable  to  the  carbonic 
acid  gas,  as  is  assumed  by  some  authors,  but  rather  to  the  large 
quantities  of  water  which  the  patient  is  able  to  imbibe  without  dis- 
tress, for  the  quantity  of  the  gas  absorbed  into  the  blood  through 
the  walls  of  the  stomach  is  certainly  too  small  to  produce  systemic 
effects. 


INDICATIONS    FOR    THE    USE    OF    ACIDULOUS    WATERS.  3I5 

The  acidulous  waters  have  been  chiefly  recommended  in  gastric 
disorders,  especially  those  of  neurotic  origin  ;  and,  owing  to  their 
agreeable  taste,  they  form  excellent  table  waters.  They  relieve 
nausea,  increase  the  appetite,  and  aid  digestion  by  stimulating  the 
secretion  of  HCl.  On  account  of  their  stimulating  effect  upon  the 
peripheral  cutaneous  nervous  system,  they  have  also  been  employed 
as  baths. 


CHAPTER  VI. 

IMPORTANT  A\EDIC1NAL  AGENTS  IN  GASTRIC  THERAPY. 

I.  Hydrochloric  Acid. — This  acid  should  never  be  given  except 
where  the  analysis  of  test-meals  shows  the  absence  of  free  HCl. 
For  this  purpose  it  is  not  sufficient  to  test  with  Congo  paper  or 
dimethylamidobenzol,  but  the  amount  of  the  HCl  deficit — i.  e.,  the 
amount  of  decinormal  HCl  solution  that  must  be  added  until  the 
reaction  of  the  chyme  shows  free  HCl — must  be  determined,  in 
order  to  be  instructed  how  much  behind  the  normal  secretion  the 
case  may  be. 

HCl  is  given  in  the  absence  or  diminution  of  the  normal  secre- 
tion mainly  for  three  purposes:  (i)  To  supplement  gastric  proteo- 
lysis; (2)  to  act  as  an  antiseptic;  (3)  as  a  tonic  and  stomachic. 

To  these  effects,  that  we  have  in  mind  in  supplying  HCl,  may 
be  added  its  influence  as  an  important  regulator  of  the  gastric 
peristalsis  ;  and  that  it  brings  the  insoluble  calcium  and  magnesium 
salts  of  the  ingesta  into  solution  ;  in  fact,  all  of  the  objects  and  func- 
tions that  are  recognized  as  physiological  to  the  HCl  (see  p.  49) 
may  be  at  least  partially  accomplished  by  supplying  it  in  sufficient 
quantity.  But  the  question  arises,  Can  it  be  supplied  in  sufficient 
quantity?  The  simple  presence  of  free  HCl  does  not  contraindi- 
cate  the  administration  of  the  acid.  Positive  reaction  to  Congo  paper 
and  phloroglucin-vanillin  indicates,  it  is  true,  that  HCl  is  secreted  in 
excess  of  what  is  required  to  combine  with  the  food.  In  healthy 
digestion  it  is  always  found  that  this  excess  amounts  on  the  aver- 
age to  30  c.c.  of  a  decinormal  solution  of  NaOH  (in  Baltimore);  and 
it  seems  to  be  what  is  necessary  or  advantageous,  not  for  digestive 
purposes  (for  even  with  a  large  excess  of  HCl  it  is  not  the  rule  for 
all  the  proteid  matter  to  be  digested  in  the  stomach),  but  for  de- 
stroying the  exuberance  of  micro-organisms  swallowed  with  the 
food.  The  frequently  quoted  cases  without  any  gastric  secretion 
whatever,  who  succeed  in  maintaining  their  nitrogen  equilibrium, 
— and  we  have  seen  many  such, — and  the  experiment  with  the  dog 
(Kaiser  and  Czerny),  whose  weight  was  kept  up  although  the  largest 

316 


LOSS    OF    HCl    SECRETION    DISPOSES    TO    ILL    HEALTH.  317 

portion  of  the  stomach  was  removed,  constitute  but  a  weak  argu- 
ment against  the  therapy  of  HCl.  For  although  such  patients 
manage  to  get  along  fairly  well,  it  is  only  under  the  most  careful 
diet  and  by  taking  very  little  exercise  that  the}-  maintain  their 
health.  Permanent  and  perfect  health  with  total  absence  of  gastric 
secretion  is  rarely  observed,  except  in  those  who  are  able  to  rest 
much  and  have  their  food  prepared  with  great  care.  These  facts 
must  not  be  overlooked  in  the  work  of  von  Xoorden  ("Ueber  die 
Ausniitzungder  Nahrung  bei  ?vlagenkranken,"  Zeitsch'ifi  f.  klm. 
Med.,  1890,  Bd.  xvii),  which  demonstrated  that  absolute  and  per- 
manent deficiency  of  gastric  juice  may  be  accompanied  by  perfect 
health.  This  health  is  perfect  under  the  conditions  mentioned,  but 
when  they  are  taxed  by  work  or  the  diet  is  not  the  usual  one,  suffer- 
ing becomes  manifest.  If  achylia  gastrica  could  really  exist  without 
any  subjective  or  objective  disturbance,  how  is  it  that  so  many  of 
these  patients  consult  the  stomach  specialists  and  are  reported  by 
them  in  literature  ?  When  we  must  work  for  our  living  and  can  not 
have  the  benefits  of  the  dietetic  kitchen  at  all  times,  we  must  have  a 
good  gastric  juice  to  partially,  at  least,  disinfect  and  dissolve  our 
food,  and  a  person  who  secretes  no  gastric  juice  is  or  soon  becomes  a 
patient.  In  a  recent  article  on  achylia  gastrica  by  F.  jMartius  and  O. 
Lubarsch  (published  by  T.  Deuticke,  Leipzig,  1S97J,  the  authors 
arrive  at  the  conclusion  that  neither  simple  achylia  nor  that  depen- 
dent upon  atrophy  of  the  mucosa  (anadenia)  can  bring  about  severe 
anemic  or  cachectic  conditions  unless  motor  insufficiency,  atro- 
phy of  the  intestinal  mucosa  or  general  diseases  (tuberculosis, 
lues,  infections,  etc.)  are  added.  Even  if  this  is  true,  generally 
speaking  it  does  not  disprove  the  statement  that  absence  of 
HCl  in  the  gastric  secretion  compels  the  individual  to  lead  the 
life  of  a  patient.  But  over  and  beyond  this,  Flint  {loc.  cit.).  Fen- 
wick  {The  Lancet,  1877),  Quinke  [^Sanwil.  klin.  Vortrdge,  Xo.  100, 
1876),  Nothnagel  {DeiUscli.  Arch.  f.  klin.  Med.,  Bd.  xxiv,  1879), 
Osier  [Anier.  Jour.  Med.  Sciences,  April,  1 897),  Kinnikut  [Amer. 
Jour.  Med.  Sciences,  October,  1887),  also  Rosenheim  and  G.  Meyer 
(both  in  article  on  "  Achylia,"  by  Martius  and  Lubarsch),  have 
described  cases  of  pernicious  anemia  in  which  atrophy  of  the  gas- 
tric mucosa  was,  at  the  autopsy,  found  to  be  the  only  organic 
disease  existing.  It  is  conceivable  that  the  intestine  can  not  per- 
sistently digest  an  amount  of  proteid  sufficient  to  maintain  the 
nitrogen  equilibrium   during  work  ;  that  it  depends  upon  a  certain 


3l8  IMPORTANT    MEDICINAL    AGENTS    IN    GASTRIC    THERAPY. 

part  of  this  proteolysis  to  be  performed  by  the  stomach  ;  that  the 
acid  gastric  chyme  is  necessary  for  the  stimulation  of  the  duodenal 
secretions.  It  is  probable  that  digestion  in  the  duodenum  is  not 
perfect  without  this  acid  chyme,  which,  as  we  know,  certainly 
causes  chemical  changes  in  the  bile. 

So  we  take  the  ground  that  the  supplementing  of  HCl  is 
rational,  even  if  we  can  not  supply  the  deficit,  because  the  amount 
necessary  thereto  could  not  expediently  be  administered.  If  we 
can  not  always  add  sufficient  HCl  to  make  the  chyme  distinctly 
acid,  we  can  at  least  add  enough  to  disinfect  it  and  free  it  from 
a  part,  the  surplus,  of  its  germs,  and  perhaps  produce  some  of  the 
preliminary  stages  to  peptone;  for  the  acid  albumins  (syntonin),  we 
believe,  are  of  some  further  utility  in  duodenal  digestion.  In  some 
cases,  however,  we  are  enabled  to  add  enough  to  give  the  reaction 
of  free  HCl  to  the  chyme. 

According  to  Honigmann  and  von  Noorden  [ZeitscJir.  f.  klin. 
Medicin,  Bd.  xiii),  one  part  by  weight  of  pure  HCl  is  able  to  satu- 
rate i8  parts  by  weight  of  egg-albumen;  lOO  drops  of  dilute 
hydrochloric  acid,  containing  12.5  per  cent,  of  the  absolute  HCl, 
will  suffice  to  digest  15  gm.,  or  225  grs. — little  less  than  four 
drams  of  pure  egg-albumen.  Riegel  cites  this  statement  iloc.  at., 
p.  258),  evidently  to  show  how  inefficacious  100  drops  of  a  12.5  per 
cent,  solution  of  HCl  are  as  a  digestive.  (The  dilute  hydrochloric 
acid  of  the  U.  S.  Pharmacopeia  is  a  ten  per  cent,  solution.) 

The  conclusions  of  Honigmann  and  von  Noorden,  however,  are, 
in  our  opinion,  not  calculated  to  inspire  therapeutic  skepticism; 
four  drams  of  dried  egg-albumen  is  a  considerable  quantity  to  be 
relieved  of,  and  it  can  not  fail  to  ease  gastric  digestion  to  give  the 
acid,  even  if  it  can  do  no  more  work  than  this. 

Riegel  himself  succeeded  in  causing  a  resumption  of  secretion 
of  HCl  in  a  patient  who  had  not  shown  any  for  months,  after  he 
had  taken  1.5  gm.  of  hydrochloric  acid  daily  for  fourteen  days. 
He  believes,  however,  that  diet  and  lavage  may  have  had  much  to 
do  with  the  recovery. 

Reichmann  and  Mintz  (^VVienei-  klin.  Wochenschr.,  1892)  report 
several  cases  in  which  free  HCl  could  be  again  demonstrated  after  it 
had  been  missing  for  a  prolonged  time ;  the  resumption  of  HCl 
secretion  was  attributed  by  them  to  a  prolonged  dosage  with  the 
same  acid.  As  we  shall  see  in  the  chapter  on  "  Achylia,"  this 
disease  may  depend  on  a  number  of  very  different  factors.     Some- 


DIGESTIVE    POWER    OF    THERAPEUTIC    DOSES    OF    HCl.  3I9 

times  there  is  no  evidence  of  pathological  change  in  the  mucosa, 
and  naturally  these  may  readily  recover  (neuroses),  even  without 
HCl  treatment. 

Professor  Biedert  claims  to  have  used  120  drops  of  dilute  HCl 
daily  for  a  number  of  years,  with  much  benefit  (Biedert  and  Lan- 
germann,  "  Diatetik  u.  Kochbuch  f  ]\Iagenkranke,"  1895)  to  his 
achylia.  Hanni  introduced  into  the  stomach  400  c.c.  of  a  2.5  per 
1000  solution  of  HCl,  containing  also  two  gni.  of  pepsin,  together 
with  an  Ewald  test-breakfast.  As  early  as  fifteen  minutes  afterward, 
when  some  of  the  test-meal  was  withdrawn,  the  free  HCl  had  com- 
pletely disappeared  and  the  digestive  power  of  the  sample  was 
equal  to  zero  (Hanni,  Zeitschr.  f.  kli/i.  Med.,  Bd.  xix,  Supplement, 
p.  307) ;  and  Boas  cites  this  statement  to  show  that  the  digestive 
value  of  HCl  therapy  is  doubtful.  Now,  a  patient  who  gets  rid  of 
400  c.c.  of  liquid  in  fifteen  minutes  has  hypermotility ;  so  much 
could  not  possibly  be  absorbed  in  that  short  period.  Xor  could 
all  of  one  gm.  of  absolute  HCl  which  400  c.c.  of  a  2.5  per  1000 
solution  contain  enter  into  combination  with  the  proteid  of  a  single 
roll;  for  100  gm.  of  wheat  roll  contain  only  seven  gm.  of  nitrog- 
enous or  HCl-binding  materials.  We  know,  however,  that  one 
gm.  of  absolute  HCl  can  digest  18  gm.  of  dried  egg-albumen. 
Therefore  the  400  c.c.  had  probably  all  been  rapidly  expelled  into 
the  duodenum  before  they  could  even  be  thoroughly  triturated 
with  the  test-breakfast.  Now,  does  this  occur  normally,  and  are 
we  justified  in  drawing  conclusions  from  such  h\'perkinetic  cases 
regarding  the  value  of  HCl  therap}- ? 

As  the  amount  of  absolute  HCl  introduced  in  Hanni's  experi- 
ments equaled  one  gm.,  and  as  so  much  could  not  enter  into  com- 
bination with  the  proteid  of  one  roll,  or  lOO  gm.  of  wheat  bread,  it 
stands  to  reason  that  if  the  motility  had  not  been  so  exaggerated, 
some  of  the  HCl  would  have  been  regained.  Whenever  Henne  {he. 
cit.,  p.  306)  succeeded  in  regaining  some  of  the  solution  of  HCl  after 
it  had  remained  in  the  stomach  forty-five  to  sixty  minutes,  or  even 
thirty  minutes  (see  cases  No.  3,  Schmid,  and  No.  4,  Hanni, 
p.  307,  loc.  cit.),  the  tests  for  HCl  were  positive  and  fibrin  was  well 
dige.sted  by  the  filtrate.  The  experiments  of  von  ]>.Iehring,  ^loritz,' 
and  myself  apparently  agree  in  permitting  the  deduction  that 
fifteen  minutes  is  an  abnormally  rapid  time  for  the  expulsion  of 
400  c.c.  of  Hquid  (even  if  it  were  only  water)  into  the  duode- 
num, and  whenever  there  is  a  fuller  meal  given  than  a  simple  test- 


320  IMPORTANT    MEDICINAL    AGENTS    IN    GASTRIC    THERAPY. 

breakfast  it  does  not  occur,  because  solid  and  semi-solid  matter 
can  not  be  moved  out  so  readily.  Again,  we  must  make  allowance 
for  a  certain  unavoidable  nervous  tension,  and  for  the  influence  of 
suggestion,  which  takes  hold  of  patients  under  experimentation, 
and  which,  from  experience,  we  know  has  a  decided  influence  on 
the  rate  of  peristalsis. 

A  careful  series  of  analyses,  constituting  a  rational  basis  for 
HCl  therapy,  are  those  of  Charles  E.  Simon  ("The  Modern 
Aspect  of  Indicanuria,"  Amer.  Jour.  Med.  Sciences,  Aug.,  1895, 
p.  170).     We  submit  a  number  of  his  conclusions  : 

"(i)  The  gastric  juice  possesses  antiseptic  and  germicidal 
properties. 

"  (2)  These  properties  are  referable  to  the  presence  of  free 
hydrochloric  acid. 

"(3)  A  subnormal  amount  of  free  hydrochloric  acid  will  call 
forth  an  increased  degree  of  intestinal  putrefaction. 

"(4)  The  conjugate  sulphates  form  an  index  of  the  degree  of 
intestinal  putrefaction. 

"  (5)  The  increased  intestinal  putrefaction  in  cases  of  subacidity 
and  anacidity  of  the  gastric  juice  is  largely  referable  to  an  increased 
formation  of  indol. 

"  (6)  The  elimination  of  indican  in  the  urine  may  be  regarded 
as  an  index  to  the  amount  of  free  hydrochloric  acid  present. 

"(7)  A  normal  acidity  of  the  gastric  juice  is  never  associated 
with  increased  indicanuria. 

"(8)  Cases  of  ulcer  of  the  stomach  apparently  form  an  exception 
to  this  rule,  an  increased  indicanuria  being  usually  associated  with 
hyperchlorhydria. 

"(9)  In  other  cases  of  hyperchlorhydria  a  subnormal  or  normal 
amount  of  indican  is  eliminated." 

We  therefore  recommend  hydrochloric  acid,  believing  in  its 
efficacy  in  supplementing  the  digestive  work  of  the  stomach. 
Whenever  it  is  indicated  we  usually  give  20  drops  of  the  diluted 
HCl  (U.  S.  Pharm.)  in  two  ounces  of  water  every  half-hour, 
beginning  fifteen  minutes  before  the  meal ;  then  20  drops  are 
taken  during  the  eating,  and  20  drops  one  half-hour  after  the 
meal.  The  medicine  should  always  be  taken  through  a  glass 
tube,  and  the  mouth  rinsed  with  a  weak  solution  of  sodium  car- 
bonate afterward.  As  a  remedy  for  improving  the  appetite,  HCl  is 
conceded,  even  b}-  those  skeptical  of  its  digestive  power,  to  be  of 


INDICATIONS    AND    CONTRAINDICATIONS    TO    HCl    THERAPY.       32 1 

value.  For  this  purpose  it  is  best  given  in  small  doses  diluted 
with  water  (lo  to  20  drops  in  5iij  HoO),  on  an  empty  stomach,  be- 
fore meals.  With  regard  to  its  disinfectant  and  anti-fermentative 
effect  we  entertain  serious  doubts,  since  it  can  not  be  given  in  suf- 
ficient quantity  to  be  of  much  benefit  in  that  direction  when  given 
with  meals.  Whenever  there  are  decided  fermentations  in  the 
stomach,  lavage  is  the  most  effective  means  of  combatting  it,  and 
for  this  purpose  HCl  in  the  form  of  a  six  per  cent,  solution  ma}-  be 
used. 

Hydrochloric  acid  is  contraindicated  when  the  normal  gastric 
secretion  is  augmented.  We  have  observed  cases  in  Avhich  there 
was  no  free  H  CI  to  be  detected  by  Congo-paper  or  phloroglucin-vanil- 
lin,  but  HCl  given  per  os  produced  gastric  distress  and  pain;  so 
that  there  can  be  no  doubt  that  cases  of  hyperesthesia  toward  HCl 
exist  analagous  to  those  described  by  Talma  {Zeitsclir.  f.  klin.  Med., 
Bd.  viii),  which  do  not  depend  upon  hyperchylia.  One  lady 
patient  could  detect  whenever  three  drops  of  the  diluted  acid  were 
given  surreptitiously  in  the  meals  or  medicine  by  the  gastralgia 
caused  thereby.     This  was  a  highly  neuropathic  case. 

The  amount  of  HCl  consumed  in  the  digestion  of  albumin  has  been 
very  carefully  studied  by  Fleischer.  It  takes  0.03  gm.  of  HCl  to 
transform  one  gm.  of  egg-albumen  into  acid  albumin.  As  human 
beings  frequently  take  in  150  gm.  of  egg-albumen  in  twent}--four 
hours,  it  would  require  7.5  gm.  of  pure  HCl.  (or  30  gm.  of  the  25 
per  cent,  solution  of  the  laboratories)  to  transform  this  amount 
into  acid  albumin.  As  the  gastric  juice  contains  HCl  to  the 
amount  of  two  per  mille,  3^-2  liters  of  gastric  juice  would  be 
required  to  digest  that  amount  of  egg-albumen.  Many  children  con- 
sume about  one  liter  of  milk  daily;  this  would  require  4.5  gm.  of 
pure  HCl  or  18  gm.  of  a  25  per  cent,  solution  of  HCl.  1 100  gm.  of 
cows'  milk  combined  with  0.45  gm.  of  HCl).  These  amounts  of  HCl 
would  bring  the  ingested  albumen  only  to  the  stage  of  acid  albu- 
min or  syntonin ;  but  as  hemialbuminose  and  peptone  would 
require  twice  the  amount  of  HCl,  the  quantity  combined  with 
must  eventually  be  increased  beyond  the  figures  stated.  A  portion 
of  the  albuminous  foods  passes  over  into  the  intestine,  however, 
and  is  there  digested  long  before  it  reaches  the  stage  of  hemialbu- 
minose ;  but  when  the  transit  of  the  food  into  the  duodenum  is 
obstructed,  it  is  evident  that  enormous  quantities  of  HCl  must 
be   secreted  to   digest   all   the    albumin    that   is   taken  in.     For  a 


6^- 


IMPORTANT    MEDICINAL    AGENTS    IN    GASTRIC    THERAPY. 


purely  physiological  reason,  it  is  not  possible  that  the  glandular 
layer  can  secrete  the  requisite  amount.  The  absence  of  free  HCl 
in  these  cases  may  be  due  to  an  invasion  of  the  mucosa  by  the 
disease  causing  the  obstruction.  It  is  not  impossible,  however, 
that,  even  without  this  invasion,  the  mucosa  has  become  exhausted, 
its  secretory  function  being  paralyzed. 

The  Alkalies. — Probably  the  earliest  experiments  upon  the 
effect  of  alkalies  on  the  gastric  secretion  are  those  by  Claude  Ber- 
nard, who  found  that  in  small  doses  they  increased  the  secretion 
of,  and  in  large  doses  they  neutralized,  the  gastric  juice  in  animals. 

Leube  (in  von  Ziemssen's  "  Handbuch,"  Bd.  vii)  stated,  as  a 
result  of  experiments  on  dogs  with  gastric  fistulae,  that  the  car- 
bonate of  soda  of  the  Carlsbad  springs  not  only  neutralized  an 
excess  of  acid,  but  could  cause  a  lasting  increase  in  the  HCl 
formation  of  a  diseased  mucosa. 

Du  Mesnil  {Deutscli.  vied.  Wochenschr.,  1892),  and  Linossier  and 
Lemoine  (Academie  de  Medecin  de  Paris,  session  of  March,  1893) 
agree  in  stating  that  when  sodium  bicarbonate  is  given  together 
with  a  test-breakfast,  or  shortly  before  it,  it  acts  as  an  excitant  to 
the  mucosa  and  increases  the  percentage  of  HCl  formed.  Du 
Mesnil  found  in  a  case  of  hyperacidity  that  the  amount  of  HCl 
was  at  once  reduced.  Indeed,  the  results  of  various  experimenters 
differ  according  to  the  normal  or  abnormal  state  of  the  stomach 
with  which  they  worked.  It  makes  much  difference,  also,  whether 
an  alkali  is  given  on  an  empty  stomach,  with  very  little  or  no 
secretion,  when  it  may  possibly  act  as  an  irritant  to  the  mucosa 
and  set  up  a  secretory  reaction,  or  whether  it  is  given  at  the  height 
of  digestion  and  meets  with  free  HCl ;  in  the  latter  case  it  must  of 
necessity  combine  with  the  acid,  and  can  cause  no  further  secre- 
tion. 

It  is  unfortunate  for  the  evolution  of  truth  in  this  question — that 
is,  whether  or  not  small  doses  of  alkali  can  stimulate  secretion — that 
quite  a  number  of  experimenters  (Ewald  and  Sandberg,  Leube, 
Spitzer,  etc.)  worked  with  Carlsbad  salts  or  water  instead  of  with 
a  chemically  pure  simple  salt.  The  people  of  other  countries  do 
not  share  that  intense  interest  in  the  Carlsbad  and  other  springs 
with  the  physicians  of  Europe;  or  at  least  those  of  Germany  and 
Austria. 

There  are  not  a  few  prominent  representatives  among  the  Ger- 
man  clinicians   who   have    expressed    grave    doubts   whether  the 


ACTION    OF    ALKALIES    ON    SECRETION.  323 

cures  and  improvements  reported  are  really  due  to  the  waters  of 
Carlsbad,  but  that  the  credit  must  be  given  to  the  avoidance  of 
bad  home  influences,  the  careful  diet,  the  regular  life,  pure  air, 
good  sleep,  and  abstinence  from  alcohol  (see  p.  302).  Personally,  we 
consider  it  our  duty  to  emphasize  that  the  waters  of  the  Congress 
and  Hathorn  Springs,  of  Saratoga,  N.  Y.,  and  of  the  Bedford  Springs, 
in  Pennsylvania,  have  produced  cures,  and,  where  they  were  not 
possible,  great  alleviation  of  gastric  diseases  there  treated.  But  even 
here  it  is  impossible  to  ignore  the  good  which  the  strict  observance 
of  the  factors  of  hygiene  and  diet  above  mentioned  may  have 
worked. 

The  natural  Carlsbad  Sprudel  salt  has  the  following  composi- 
tion, according  to  Prof  E.  Ludwig  : 

Sodium  sulphate, 41.62  per  cent. 

Potassium  sulphate, 3.31  " 

Sodium  bicarbonate, 36.1 1  " 

Lithium  carbonate, 0.2  " 

Sodium  chlorid, 18.19  " 

Sodium  borate, 0.03  " 

Water, 0.44  " 

The  artificial  Carlsbad  salt,  which,  according  to  Boas,  can  fully 
replace  the  more  expensive  natural  salt,  contains  the  following 
salts,  according  to  the  German  Pharmacopeia  : 

-Sodium  sulphate  (dried), 44  parts. 

Potassium  sulphate, 2     '•' 

Sodium  chlorid, 18     " 

Sodium  bicarbonate, 36     " 

In  hyperchylia  and  h}'persecretion  (in  gastric  ulcer)  it  is  given  in 
doses  of  one  to  two  dessertspoonfuls  in  \;^  of  a  liter  of  water, 
to  reduce  the  excess  of  HCl  and  promote  evacuation.  In  gastritis 
it  is  also  recommended,  and  this  has  seemingly  given  the  Carlsbad 
enthusiasts  much  difficulty,  namely,  to  explain  how  the  identical 
solution  may  produce  reduction  of  the  HCl,  and  in  another  case 
promote  HCl  formation. 

We  have  studied  eight  cases  who  went  to  Carlsbad  suffering 
from  subacidity  and  from  achylia;  we  have  not,  in  a  single  instance, 
observed  a  return  of  secretion  where  it  was  lost  or  an  increase 
where  it  was  deficiently  formed. 

Reichmann  is  one  of  the  few  who  objected  to  applying  the  deduc- 
tions found  with  Carlsbad  water  or  salts,  on  account  of  their  com- 


324  IMPORTANT    MEDICINAL    AGENTS    IN    GASTRIC    THERAPY. 

plexity  to  the  effects  of  pure,  simple  alkaline  salts  {Thcrapei<t. 
Monatsheftc,  1895).  We  have  never  shared  the  opinions  of  those 
who  believe  that  small  doses  of  alkali  given  on  an  empty  stomach 
can  produce  a  reactive  secretion  of  HCl  which  may  exceed  the 
amount  necessary  to  combine  with  the  alkali  given.  We  can 
understand  that  strong  solutions  of  sodium  and  potassium  sulphate, 
such  as  the  Carlsbad  water,  may  actually  play  the  role  of  an  irri- 
tant, to  which  the  mucosa  responds  in  the  form  of  an  increased  secre- 
tion, just  as  the  nasal  mucosa  would  do  if  a  crystal  of  salt  were  placed 
in  the  nasal  passage.  Indeed,  N.  Reichmann  declares,  after  a  series 
of  careful  analyses  with  Na^COs,  that  the  bicarbonate  of  sodium  does 
not  act  upo7i  the  secretory  mechanism  of  the  stomach,  but  only  upon 
the  Juice  already  secreted,  by  neutralizing  it  and  rendering  the  gastric 
contents  alkaline  (Boas,  Archiv  f.  Verdaiiungskrankh.,  vol.  i,  p.  44). 

The  actual  therapeutic  application  of  alkalies  is  limited  to  those 
dyspepsias  associated  with  increased  HCl  formation,  in  simple  neu- 
rasthenic hyperchylia  in  hypersecretion  and  in  gastric  ulcer.  They 
are  indispensable  for  lavage  when  it  becomes  necessary  to  neutral- 
ize acids  and  dissolve  adherent  mucus.  The  time  to  give  alkalies 
in  hyperacidity  is  from  one-half  to  one  hour  after  meals,  when  the 
HCl  secretion  is  quantitatively  at  its  height.  The  sensations  of  the 
patient  are  a  very  good  guide,  and  the  time  can  be  learned  by  expe- 
rience ;  the  alkali  should  then  be  given  a  little  previous  to  the  time 
when  the  gastralgia,  eructation,  pyrosis,  and  distention  set  in.  In 
hypersecretion  there  is  a  large  amount  of  HCl  present  almost  con- 
tinuously in  the  empty  stomach,  in  addition  to  hyperacidity  after 
meals,  so  here  we  should  give  alkalies  before  meals  in  order  to 
insure  a  certain  time  for  action  to  the  ptyalin  ;  for  this  constant 
secretion  a  glass  of  Saratoga  Vichy,  or  simply  sodium  bicarbonate 
5j,  in  plain  cold  water,  before  meals,  is  sufficient  to  permit 
amylolysis.  In  ulcer  and  chronic  gastritis  acida,  alkalies  find 
application  also  (refer  to  treatment  of  these  diseases). 

Determination  of  the  Amounts  of  Alkalies  Required. — Two  groups 
of  these  bodies  are  in  common  use:  (i)  The  alkaline  earths,  (2) 
the  alkaline  carbonates.  Of  the  first  group,  magnesia  usta  or 
calcined  magnesia,  and  the  more  expensive  magnesium  ammonium 
phosphate  are  the  favorites ;  and  of  the  second,  the  sodium  car- 
bonate and  bicarbonate.  Those  alkalies  which  are  capable  of  com- 
bining with  the  largest  amount  of  HCl  are  preferable.  It  is  expe- 
dient to  avoid  excess  of  sodium  bicarbonate,  because  the  liberation 


ADMINISTRATION    OF    ALKALIES.  325 

of  COo  in   the  neutralization    may   cause  annoying   distention   of 
muscular  walls  already  infirm. 

Magnesia  usta  has  the  greatest  binding  power  for   HCl,  and  the 
reaction  is  expressed  in  the  following  equation  : 
MgO  —  2HCI  =  MgCl,  -f  2H2O. 

Here  0.55  equivalents  of  MgO  correspond  to  one  equivalent  of 
HCl. 

The  reaction   with   ammonio   magnesium   phosphate  is  the  fol- 
lowing : 

Mg(XHJPO^  +  3HCI  =  MgCU  4-  NH^Cl  4-  HgPO^. 

Calculation   here  gives  the  result  that   1.25   parts  by  weight  of 
Mg(NHjt)POi  correspond  to  one  part  by  weight  of  HCl. 
The  reaction  with  sodium  bicarbonate  is  as  follows  : 
NaHCO,  —  HCl  =  NaCl  —  H,0  —  CO,. 

Calculation  of  the  molecular  weights  shows  that  2.3    equivalents 
of  NaHCOo  correspond  to  one  of  HCl. 

According  to  Boas,  the  dose  of  sodium  bicarbonate  necessar\-  to 
counteract  a  superacidity  exceeding  2.5  pro  1000  is  eight  to  ten  gm., 
or  four  to  six  gm.  of  ammonio  magnesium  phosphate,  or  two  to 
three  gm.  of  magnesia  usta.  With  an  acidity  of  three  pro  1000  HCl, 
the  NaHCOo  can  be  increased  to  12  gm.,  the  ammonio  magnesium 
phosphate  to  7.5  gm.,  and  the  magnesia  usta  to  five  gm.  These 
calculations  are  made  upon  an  amount  of  stomach  contents  equal 
to  400  c.c. ;  but  as  a  part  of  the  alkali  is  expelled  into  the  duode- 
num, another  part  absorbed,  and  as  the  momentary  quantity  of 
HCl  present  can  only  be  reckoned  upon,  the  figures  may  be  too 
low.  With  constipation  and  collection  of  gas  in  the  intestines  the 
preference  is  to  be  given  to  the  magnesia  salts.  Germain  See 
{Semaine  Medicale,  1890,  No.  12)  recommends  the  following: 
R.  Sod.  bicarb., 
Cretae  prsep., 

Magn.  carbon., aa  .    .    .     0.2  gm.  M. 

Take  at  once. 

Boas'  formula  for  continued  excessive  secretion  is  the  following : 

Metric 
System. 

R.      Magnesiae  ustae, 15.0  gi-.  231.5 

Bismutli.  carbon., 

Natrii  carbon. , aa  .    .    ,    .     5.0  gr.     77.2 

Extr.  belladonnae, 

Extr.  str>'chni, aa  .    .    .    ,    0.1-0.2        gr.       1.7.      M. 

SiG. — One  teaspoonful  three  times  daily,  half  an  hour  after  meals. 


326  IMPORTANT    MEDICINAL    AGENTS    IN    GASTRIC    THERAPY. 

The  amount  of  HCl  secreted  should  be  watched  and  the  alkali 
discontinued  if  it  becomes  normal. 

The  Bitter  Tonics  and  So-called  Stomachic  Remedies. — 
Experience  has  lent  belief  that  the  bitter  tonics  are  agents 
which  stimulate  the  appetite  and  the  secretory  and  motor  func- 
tions of  the  stomach.  They  are  represented  by  preparations  of 
condurango,  quassia,  Colombo,  gentian,  angostura,  absinthe,  nux 
vomica  and  strychnin,  creasote,  guaiacol,  orexin,  lupulin,  cetrarin, 
erythrocentaurin,  rheum,  resorcin,  quinia,  cinchona.  Under  cer- 
tain conditions,  HCl,  sodium  chlorid,  and  alcohol  act  as 
stomachics. 

Some  writers  class  sodium  bicarbonate  among  these  remedies, 
upon  the  supposition  that  small  doses  of  this  alkali  may  stimulate 
secretion  of  gastric  juice;  this  therapy  is,  in  our  opinion,  falla- 
cious. As  a  general  rule,  these  medicines  are  useful  to  improve 
the  appetite,  and  as  anorexia  is  mostly  found  in  reduced  or  lost 
gastric  secretion,  the  effect  upon  secretion  is  apparently  the  only 
one  that  can  be  attributed  to  them.  What  the  bitter  tonics  really 
effect  and  how  they  act  is  an  unsolved  problem.  There  seems  to 
be  an  absence  of  scientific  exactness  in  many  of  the  experiments, 
and  a  general  diffusiveness  regarding  the  special  point  of  inquiry 
to  be  solved  ("  Fragestellung ").  Thus,  Penzoldt  pretends  that 
genuine  stomachics  must  be  able  to  improve  all  of  the  gastric 
functions  (Penzoldt,  on  "Salzsaures  Orexin,"  Therap.  MoiiatsJi.,  1890, 
No.  2).  Loss  of  appetite  may  be  present  when  the  functional  work 
is  reduced,  and  then  bitter  tonics  would  be  indicated ;  but  it  may 
just  as  well  be  present  with  normal  or  morbidly  increased  functions 
when  stomachics  would  do  harm.  We  have  had  many  cases  of 
anorexia  with  hyperacidity  where  the  appetite  returned  after  the 
use  of  bromid  of  strontium.  In  dilatations  with  fermentation  the 
best  stomachic  is  lavage.  As  every  disturbed  function  or  disease 
requires  elucidation,  so  the  anorexia  based  thereon  demands  its 
own  adapted  treatment.  Bitter  tonics  and  allied  medication  are,  in 
general,  stimulants  to  the  mucosa,  and  although  they  have  a  large 
application,  it  is  not  rational  to  use  them  empirically.  A  sedative 
or  an  antiseptic  may,  under  certain  conditions,  be  a  better  medicine 
than  the  bitter  tonic  for  anorexia.  The  most  rational  course  to 
pursue  is  to  ascertain  the  exact  state  of  the  gastric  functions,  and 
after  the  establishment  of  the  diagnosis  attempt  to  remove  the 
cause  of  the  anorexia,  whether  it  is  depressed  motility,  dilatation,  or 


ACTION    OF    BITTER    TONICS.  327 

achylia.  For  a  fuller  account  of  the  physiological  effects  of  these 
remedies  the  reader  is  referred  to  recent  works  on  pharmacology 
and  therapeutics  (Hare,  H.  C.Wood,  Remington,  Sidney  Ringer; 
Schmiedeberg's  "  Arzneimittellehre,"  Binz,  "  Pharmakologie  "  ;  the 
chapters  on  this  subject  in  the  text-books  of  Riegel,  Ewald,  Boas, 
Rosenheim,  and  Wegele). 

Perhaps  the  most  useful  medicines  of  this  class,  in  our  experience, 
have  been  strychnin  and  condurango,  which,  according  to  the  ex- 
periments of  L.  V\[o\f(  (Zeitschr.  f.  klin.  Med.,  Bd.  xvi,  S.  222),  have 
no  appreciable  effect  on  the  rate  of  secretion.  Reichmann's  very 
carefully  conducted  investigations  {Zeitschr.  f.  klin.  Med.,  Bd.  xiv. 
Heft  I  und  2)  brought  out  the  fact  that  some  bitter  tonics  failed  to 
cause  any  secretion  of  gastric  juice  when  distilled  water  did. 
And  whenever  water  failed  to  produce  secretion  the  bitter  remedies 
failed  also.  On  normal  digestive  processes  these  agents  have  no 
effect ;  but  when  a  juice  was  secreted  that  was  acid,  though  not  con- 
taining HCl,  and  if  a  gastric  juice  very  weak  in  pepsin  was  secreted, 
then  the  bitter  tonics,  especially  absinthe,  were  found  to  produce  a 
stronger  degree  of  acid  and  distinct  reaction  for  HCl.  Wherever 
there  was  atrophy  of  the  glandular  apparatus,  all  of  these  remedies 
failed  to  cause  a  secretion  of  HCl  containing  gastric  juice.  In  brief, 
his  conclusions  are  that  the  effect  is  very  variable,  sometimes  less 
than  that  of  water  ;  but  sometimes  there  is  an  increase  of  secretion 
after  the  bitter  tonic  has  become  absorbed  and  disappeared.  They 
act  best  when  given  before  meals,  and  when  there  is  a  gastric 
secretion  still  present  but  much  reduced  (hypochylia).  In  hyper- 
secretion Reichmann  found  that  the  acidity  was  still  further 
increased  by  bitter  tonics.  Riegel  concludes  that  the  bitter  tonics 
should  be  given  only  in  hypochylia  or  subacidity,  and  then  one-half 
hour  before  meals.  Our  own  formula  for  anorexia  from  hypo- 
chylia is  the  following : 

Metric 
System. 
R.      Strychnin  sulphatis, 0.020  gr./^ 

Acidi  hydrochloric,  dil., 14-787  if,  ss 

Extr.  condurango, 45.361  f^jss 

EHxir  gentian, q.  s.  ad,    .    .    .  177.442         f^^^-  ^I- 

SiG. — f^  ss.  in  ^ij  aquse,  one  half-hour  before  meals,  through  a  glass  tube. 

Where  there  are  evidences  of  anemia,  with  the  hypochylia,  the 
following  acts  satisfactorily : 


328  IMPORTANT    MEDICINAL    AGENTS    IN    GASTRIC    THERAPV. 

Metric 
System. 

li .     Quinre  sulphatis,       I- 193  gr.xviij 

Strychnin  sulphalis, 0.020         gr.  \4 

Ferri  sulphatis, 0-775         gi'-'^'j 

Acidi  arseniosi, o.oi2-|-     gr.  i.  M. 

SiG. — Fiant  pil.  No.  xii.     One  pill,  three   times  daily  (must  be  prepared  fresh  and 
not  coated). 

Boas  uses  the  following  powder  for  anorexia: 

Metric 
System. 

R  .     Extr.  strychn.,       0.03  to  0.05  gr.  -^-^-j^ 

Bismuth,  carbon., .  0.5  gr.  .43-.56 

M.  f.  pulv.      Dent.  tal.  dos.  xx.  gr.  .56-^5. 
SiG. — One  powder,  three  times  daily. 

Menche  has  warmly  recommended  resorcin  sublimate,  and  it  un- 
deniably improves  the  appetite  in  cases  of  incipient  gastric  fermen- 
tation. It  has  also  a  slight  sedative  action.  The  following  is 
Menche's  formula: 

Metric 
System. 

U.      Resorcin.  resubl., 2.0     gr.  30.5 

Acid,  mur., i.o     gr.  15.4 

(Or  if  it  be   indicated  in  place  of  the  HCl,  one  may  order 

Natr.    bicarb.,  8.0.) 

Aqute  destil.,        180. o    f  5  vj 

Syr.  simpl., 20.0      jiij- 

M.  D.  et  ad  vitr.  nigr. 

SiG. — 15  c.c.  (  §  ss)  every  two  hours. 

The  following  formulae  are  recommended  by  Ewald  for  anorexia 
with  fermentation  : 

Metric 
System. 

Ijt .     Tinct.  nucis  vom., 25.0  f^vj 

Resorcin.  resublim., 5.0  gr.  81 

Tinct.  amar. , lo.o  f^iij.  M. 

Take  10  to  15  drops  every  two  hours. 

R.      Ext.   condurango,  fl., 16.0     f^^ivss 

Resorcin.  resublim., 4.0        zi.  M. 

SiG. — 30  drops,  four  times  daily. 

Creasote  is  a  remedy  of  doubtful  efficacy  in  our  experience,  as  it 
rarely  benefits  digestion  except  in  tuberculous  patients.  Wegele 
says  {loc.cit.,  p.  53)  that  it  will  help  if  it  is  tolerated  and  causes  no 
severe  dyspeptic  difficulties, but  that  is  just  what  it  will  do  in  about 


DIGESTIVE    FERMENTS — PTYALIN.  329 

one-half  of  the  cases.  We  have  our  doubts  whether  it  can  pro- 
mote peristalsis,  as  is  asserted  by  YAova^^^x^x  {Centralbl.  f.  klin.  Med., 
1 89 1,  No.  21),  until  enough  is  given  to  act  as  an  irritant.  Even 
when  it  is  tolerated  by  the  stomach,  the  repeated  penetrating  eruc- 
tations are  very  annoying  to  nervous  patients.  Sommerbrodt 
recommended  it  to  be  taken  in  capsules.  Bouchard  advises  the 
following  formula : 

Metric 
System. 

K  •  Creosot.   puriss. ,   .    .    , 13.5 

Tinct.    gent., 20.0 

Vin.  Xerens, Soo.o 

Spir.    rectif.,       200.0  M. 

SiG. —  ^  ss  four  times  daily. 

Orexin  (phenyldihydrochinazolin)  has  been  strongly  indorsed 
as  a  "  genuine  "  stomachic  by  Penzoldt.  In  273  cases  he  observed 
144  successful  restorations  of  appetite  and  secretion.  Its  special 
indications  are  gastric  atony  and  beginning  gastritis,  and  its  action 
is  attributed  to  its  power  of  increasing  the  secretion  of  HCl  (Pen- 
zoldt, "  Weitere  Mittheilungen  liber  Orexin  basicum,"  etc.,  TJierap. 
MonatsJiefte ,  May,  1893.)  The  following  formula  is  advised  by  Pen- 
zoldt for  this  useful  drug  : 

R.     Orexin  basic, ^ss.  or  2  gm. 

SiG. — Divide  into  six  powders  ;  inclose  in  small  wafers.      One  to  be  taken  in   a 
cup  of  bouillon  half  an  hour  before  meals,  twice  daily. 

Digestive  Ferments. — Artificial  means  of  aiding  digestion  are 
certainly  much  abused,  and  if  employed  for  long  periods  they 
frequently  become,  to  a  certain  extent,  injurious.  Every  organ 
is  strengthened  by  activity  and  weakened  by  lack  of  exercise.  The 
stomach  will  grow  weaker  and  weaker  the  more  artificial  gastric 
juice  is  poured  into  it,  and  the  finer  and  more  subtle  the  nourish- 
ments are  that  are  allotted  to  it  (Einhorn).  This  agrees  in  the  main 
with  what  we  stated  under  "  Dietetics,"  namely,  that  the  diet  should 
not  be  leveled  down  to  the  digestive  capabilities  of  the  stomach,  but 
that  digestion  should  be  leveled  up  until  it  can  deal  efficiently  with 
the  amount  of  food  required  for  the  nitrogen  equilibrium.  In 
truth,  the  indiscriminate  dosing  with  digestive  ferments  does  more 
harm  than  good.  The  stomach  is  an  organ  which  very  rapidly 
adapts  itself  to  cease  performing  the  work  that  is  done  for  it  arti- 
ficially. Then,  again,  there  is  such  a  thing  as  educating  an  appa- 
rently weak  stomach  up  to  digesting  food  which  at  first  seems  in- 
digestible, and  is  taken  with  "  fear  and  trembling."  So  we  will 
22 


330  IMPORTANT    MEDICINAL    AGENTS    IN    GASTRIC    THERAPY. 

find  that  gastric  training  by  graded  diet  may  favor  the  development 
of  what  fragments  of  glandular  elements  may  yet  be  slumbering 
in  a  diseased  mucosa,  but  the  irrational  use  of  ferments  ma), 
by  doing  all  the  work  itself,  permit  the  gland-cells  to  go  on  to 
atrophy. 

The  artificial  ferments  have  been  recommended  where  there  is  a 
deficiency  or  absence  of  the  natural  secretion.  They  may  be  con- 
sidered in  two  classes  :  (i)  Those  that  have  been  isolated  from  the 
mammalian  organism,  viz.,  ptyalin,  pepsin,  pancreatin  ;  and  (2)  those 
derived  from  the  vegetable  kingdom,  viz.,  the  various  diastases, 
papain,  bromilin.  Some  of  the  ferments  of  the  human  body  have 
not  yet  been  isolated  ;  these  are  the  milk-curdling  ferments  of  the 
gastric  and  pancreatic  juices,  and  the  emulsifying  and  fat- splitting 
ferments.  There  are  ferments  in  the  succus  entericus  (invertin,  etc., 
perhaps  a  curdling  ferment)  which  we  understand  very  little. 

Ptyalin. — This  ferment  of  the  saliva  is  indicated  in  h}-peracidity 
and  hypersecretion,  when  the  normal  ptyalin  may  actually  be 
destroyed.  Boas  has  shown  that  with  diminution  of  the  acidity 
this  ferment  may,  to  a  degree  at  least,  resume  its  inversion  of 
starches  into  dextrose.  With  very  intense  hyperacidity  (0.04  pro 
1000)  the  ferment  appears  to  be  so  injured  that  it  can  not  be 
restored  to  function,  and  a  new  supply  may  be  necessary.  Ptyalin 
is  given  in  doses  of  5  to  15  grs.,  with  3j  of  sodium  bicarbonate, 
immediately  after  meals.  There  can  be  no  doubt  of  the  greater 
amount  of  dextrose  formed  with  the  aid  of  ptyalin,  and  these 
patients  are  thereby  enabled  to  eat  more  of  carbohydrates. 

Diastase. — Malt  diastase,  as  manufactured  in  the  form  of  liquid 
extract,  or  in  dry  form,  as  in  Horlick's  diastoid,  is  serviceable 
for  the  same  purpose.  Recently,  Professor  Leo,  of  Bonn  [Therap. 
MoiiatsJiefte ,  Dec,  1896),  reported  to  the  Congress  of  German  Natur- 
alists and  Physicians  on  taka  diastase,  an  American  product,  which 
appears  to  have  strong  starch-inverting  power,  and  to  be  able  to  act 
in  an  amount  of  acid  equal  to  o.i  per  cent.  HCl.  We  have  assured 
ourselves  that  amylolysis  is  effectively  carried  out  by  this  taka 
diastase,  but  the  addition  of  an  alkali  is  necessary,  as  with  ptyalin, 
to  render  the  effect  prompt.  Its  tastelessness  and  moderate  price 
are  in  its  favor. 

Ewald  has  found  in  a  great  many  observations  that  absence  or 
deficiency  of  ptyalin  is  an  exceedingly  rare  thing ;  so  that  ptyalin 
is   rarely  required,  because    it    is    secreted   in  sufficient  quantity. 


SO-CALLED    "AMYLACEOUS    DYSPEPSIA" PEPSIN.  33  I 

but  in  some  way  is  destroyed.  The  hygiene  of  the  mouth 
should  receive  careful  attention  ;  a  septic  or  acid  mouth,  with 
coated  tongue  and  bad  teeth,  will  offset  any  amount  of  ptyalin.  To 
treat  "  amylaceous  dyspepsia  " — which  is  the  objectionable  name 
giv^en  to  symptoms  of  hyperacidity  and  hypersecretion — by  cutting 
off  the  carbohydrates,  is  irrational,  because  they  can  not  be  dis- 
pensed with,  not  on  account  of  the  starch  only,  but  on  account  of  | 
the  proteid  which  amylaceous  foods  contain.  It  will  be  found  from 
the  army  rations  of  men  under  service  of  various  nations  that  the 
carbohydrate  portion  of  the  foods  is  increased  with  harder  work 
much  more  than  the  proteid  and  fat  portion  (see  tables  in  Oilman 
Thompson's  "  Dietetics  "  and  Munk  and  Uffelmann's  "  Ernahrung 
des  Menschen  ").  Therefore  these  foods  should  not  be  taken  away, 
because  they  may  not  be  perfectly  digested  ;  but  the  cause  of  the 
indigestion  should  be,  if  possible,  removed.  If  possible,  a  large 
amount  of  natural  saliva  should  be  swallowed  after  m'eals  ;  many 
times  have  we  observed  that,  with  the  simple  supply  of  additional 
saliva  caused  by  chewing  a  piece  of  rubber,  starch  indigestion 
would  not  be  demonstrated  in  the  test-meal,  although  it  had 
existed  before.  To  Fothergill  is  attributed  the  saying  that  ferments 
are  crutches ;  no  doubt  many  an  invalid  would  prefer  walking  on 
crutches  than  not  at  all.  There  are  many  crutch-walkers,  however, 
who,  by  modern  surgery,  have  been  enabled  to  throw  them  away 
and  walk  by  themselves  unaided.  Just  so  with  the  ferments  ;  they 
may  be  used  with  success  temporarily,  but  the  best  thing  to  do 
is  to  discover  how  the  patient  may  digest  without  them. 

Pepsin. — There  is  no  lack  of  pepsin  preparations  in  the  market 
and  their  digestive  powers  as  claimed,  seemingly  have  no  limit. 
Certain  very  popular  compositions  of  pepsin  should  be  emphatically 
condemned.  For  instance,  all  wines  of  pepsin  are  inefficient 
because  \'ery  little  of  this  ferment  is  taken  up  by  alcohol.  Recently, 
a  preparation  was  brought  to  our  laboratory  containing  hydrastis, 
rhubarb,  pepsin,  and  pancreatin  in  one  solution,  showing  a  total 
disregard  for  the  physiological  fact  that  pepsin  acts  only  in  an  acid 
and  pancreatin  in  an  alkaline  medium.  There  is  rarely  any  indi- 
cation for  the  use  of  pepsin,  for  whenever  a  test-meal  shows  free 
HCl,  pepsin  must  of  necessity  be  present  in  sufficient  amounts; 
and  even  when  HCl  is  absent,  pepsin  or  pepsinogen  are,  as  a  rule,, 
still  present.  Assuming  a  case  in  which  the  last  vestige  of  even 
pepsinogen  secretion  has  been  lost,  the  introduction  of  the  ferment 


00- 


IMPORTANT    MEDICINAL    AGENTS    IN    GASTRIC    THERAPY. 


might  be  of  utility,  but  the  enormous  quantities  of  HCl  necessary 
to  bring  about  proper  action  of  this  pepsin  could  not  be  tolerated 
by  any  stomach  (see  chapter  on  the  Therapy  of  HCl).  And, 
again,  in  cases  where  pepsinogen  is  still  formed,  the  addition  of 
HCl  simply,  will  suffice  to  convert  it  into  the  complete  ferment. 
Pepsin  is  prescribed  much  too  often. 

Pancrcatin. — Although  there  are  many  preparations  of  this  fer- 
ment, and  some  of  them  very  active,  the  substance  spoils  and  loses 
its  digestive  power  with  age.  As  it  is  an  easy  matter  to  test  its  amy- 
lolytic  and  tryptic  power  in  artificial  digestion  experiments,  it  is 
wise  to  do  so  in  all  cases  where  much  dependence  is  placed  in  its 
action.  The  nature  and  value  of  the  substance  was  scientifically 
explained  by  Sir  William  Roberts  ("  Digestion  and  Diet,"  p.  66). 
It  can  be  obtained  in  a  liquid  form  as  well  as  in  the  form  of  a  dry 
powder,  from  extraction  of  the  pancreatic  gland  of  animals.  This 
ferment  is  completely  destroyed  in  the  gastric  juice.  This  is  why 
thinking  practitioners  should  not  use  both  pepsin  and  pancreatin 
together  in  the  same  solution,  because  the  medium  in  which  one 
must  act  is  opposed  to  that  of  the  other.  In  the  majority  of  cases 
where  pancreatin  is  given  empirically,  HCl  is  still  secreted  in  the 
gastric  cavity  and  the  ferment  is  destroyed.  Oilman  Thompson 
{loc.  cit.,  p.  333)  suggests  that  the  pancreatin  be  inclosed  in  keratin 
capsules,  keratin  is  unaffected  by  gastric  juice,  but  readily  dissolves, 
it  is  claimed,  in  alkaline  media.  Hence  the  pancreatin  may  pass 
through  gastric  digestion,  and  at  its  completion  pass  into  the  in- 
testine where  the  coating  is  dissolved  and  the  ferment  acts  upon 
the  chyle.  This  idea  is  not  supported  by  experiment  nor  by  ex- 
act indications  of  the  conditions  for  the  employment  of  pancreatin. 
Keratin  will  not  dissolve  in  the  alkalinity  of  the  duodenum  except 
very  slowly  ;  pills  coated  therewith  are  found  in  the  stools  during 
normal  digestion.  There  is  no  necessity  for  attempting  to  supply 
the  ferment  directly  to  the  duodenum,  since  in  the  greater  majority 
of  cases,  perhaps  all,  except  where  malignant  neoplasm,  cirrhosis,  or 
abscess  have  destroyed  the  gland,  there  is  plenty  of  pancreatic  juice 
in  that  part  of  the  bowel.  In  exceedingly  rare  cases  pancreatic  cal- 
culi and  diseased  states  of  adjacent  parts  may  stenose  the  duct. 
The  suggestion  of  Thompson  was  previously  carried  out  by  Unna. 
In  all  these  attempts  it  is  overlooked  that  the  reaction  of  the  nor- 
mal duodenum  is  acid  and  will  not  permit  the  solution  of  keratin. 

There  is  but  one  distinct  indication  for  the  use  of  pancreatin,  and 


PANCREATIN INDICATIONS    FOR    ITS    USE.  333 

that  is  permanent  deficiency  or  complete  absence  of  HCl  and 
enzyme  formation  in  the  stomach.  Experiment  and  experience 
have  conclusively  shown  that  when  pancreatic  digestion  is  in  these 
cases  started  in  the  stomach,  by  giving  the  pancreatin  with  sodium 
bicarbonate,  there  is  a  more  exhaustive  utilization  of  the  proteids 
and  carbohydrates.  We  have  frequently  assured  ourselves  of  this 
fact  by  analyzing  the  stools  after  weighed  amounts  of  these  food- 
substances  had  been  ingested,  at  the  same  time  making  identical 
analyses  with  the  same  amounts  of  proteid  and  carbohydrate,  but 
with  pepsin  hydrochloric  acid  as  an  artificial  digestant ;  under  the 
latter  more  food-substances  passed  through  undigested  than  when 
pancreatin  was  used. 

Pepsin  and  hydrochloric  acid  naturally  suggest  themselves  in 
atrophic  gastritis,  but  judging  from  our  observations  pancreatin  is 
preferable.  We  have  noticed  cases  in  which  there  was  a  remark- 
able hypersensitiveness  to  hydrochloric  acid  even  in  doses  of  six 
drops  of  the  dilute  form,  so  that  its  use  had  to  be  dispensed  with. 
The  dose  of  pancreatin  is  from  four  to  eight  grs.,  together  with  the 
same  amount  of  sodium  bicarbonate  in  form  of  compressed  tablets  ; 
of  these,  two  to  four  are  taken  fifteen  minutes  after  meals. 

Papain,  Papoid,  Papayotin. — These  ferment-containing  substances 
are  made  from  the  milky  juice  of  a  tree  belonging  to  the  family  of 
Papayacese,  native  in  Central  and  South  America. 

Bouchut  and  Wurtz  ("  Sur  la  ferment  digestiv  du  Carica  Papaya," 
Conipt.  Rend.,  1879,  tome  lxxxix)  first  prepared  papain,  and  later 
Peckolt  brought  out  papayotin.  Papoid,  an  American  preparation, 
according  to  Prof.  R.  H.  Chittenden,  is  a  vegetable  ferment  made 
up  of  vegetable  globulin,  albumoses,  and  peptone,  with  which  are 
associated  the  ferments  characteristic  of  the  preparation.  Papoid 
has  the  power  of  digesting  to  a  greater  or  less  extent  all  forms  of 
proteid  or  albuminous  matter,  both  coagulated  and  uncoagulated  • 
its  digestive  power  is  exercised  in  a  neutral,  acid,  as  well  as  alkaline 
medium.  Papoid  is  found  in  the  stools,  showing  that  it  is  not 
destroyed  in  the  alimentary  canal ;  the  dose  is  from  one  to  three 
grs.  after  each  meal. 

Finkler  prefers  papain  to  pepsin  for  aiding  gastric  digestion 
{TJierap.  Gazette,  1887,  August  15),  and  G.  Littmann  has  observed 
good  results  with  it  in  acute  and  chronic  gastritis,  dilatations,  car- 
cinoma, and  dyspepsia  after  chronic  ulcer  (Littmann,  Munch,  vied. 
WocJienschr.,  1893, No.  29). 


334  IMPORTANT    MEIMCINAL    AGENTS    IN    GASTRIC    THERAPY. 

Papain  seems  to  be  a  variable  product  and  its  digestive  action 
not  always  the  same  (Rossbach  and  A.  Eulenberg).  It  is  an 
expensive  preparation.  Recently  a  highly  concentrated  extract  of 
carica  papaya  has  been  brought  into  the  market  under  the  name  of 
Caroid,  which,  according  to  Chittenden,  has  even  a  greater  digestive 
power  than  papoid,  and  digests  proteids,  albumins,  and  starches  in 
any  medium.  We  append  Chittenden's  results  with  this  energetic 
ferment,  concerning  the  clinical  application  of  which  further  obser- 
vations are  necessary : 

Witli  0.0 J  per  cent,  liydrocliloric  acid. 

Undigested  residue.  Proteid  digested. 

Caroid, 0.8024  gm.  20.2  per  cent. 

Papain,  A.,      0-8959    "  io-9         " 

Papain,  B.,       0.8735    "  13. 1  " 

Witli  O.J  per  cent  sodinni  bicarbonate. 

Undigested  residue.  Proteid  digested. 

Caroid, 0.4596  gm.  54-3  pcr  cent. 

Papain,  A.,       0.5691    "  43-4         " 

Papain,  B.,       0.5927    "  41.0         " 

If  we  examine  these  results  critically  it  is  plain  that  the  digestive 
power  of  caroid  on  proteid  matter  is  greater  than  that  of  the  other 
two  preparations.  The  difference  in  digestive  strength  is  more 
apparent  in  these  experiments  with  coagulated  egg-albumen  than 
with  the  other  form  of  proteid  matter,  although  quite  marked  with 
blood-fibrin. 

2.  Starch-digesting  Pozver. — In  starch-digesting  power  caroid 
is  far  superior  to  the  other  preparations,  either  papoid  or  papain. 
The  following  experiments  will  throw  some  light  upon  this  point. 

A  starch  paste  was  made  from  five  gm.  of  dry  arrowroot  starch 
with  500  c.c.  of  water.     Mixtures  were  then  prepared  as  follows: 

1.  0.5  gm.  of  caroid,  4-  90  c.c.  water  +    10  c.c.  of  starch  paste. 

2.  0.5        "        "     papoid,  +  <;  11  _|_  <.        .1  li  <: 

3.  0.5     "     "   papain,  A., -|-  "        "        -|-  'i     <<        u  <; 

4.  0.5     "     "   papain,  B.,  -f-  <<        .i        _j_  <<      <<        <i  <i 

These  four  mixtures  were  placed  at  40°  C,  and  tested  from  time 
to  time  with  iodin  solution.  In  five  minutes  No.  i  had  reached  the 
achromic  point,  while  No.  2  did  not  give  the  achromic  reaction 
until  at  the  end  of  two  hours.  At  the  end  of  three  hours,  Nos.  3 
and  4  still  gave  a  bluish-violet  reaction  with  iodin. 

In  another  series  of  experiments,  exactly  similar  to  the  above, 


PROTEOLYTIC    FERMENT    OF    THE    PINEAPPLE.  335 

except  that  each  mixture  contained  only  0.2  gm.  of  ferment,  the 
caroid  brought  about  a  complete  conversion  of  the  starch  into 
bodies  noncolorable  by  iodin  in  eighteen  minutes,  while  the  others 
gave  a  blue  reaction  after  two  to  three  hours. 

The  presence  of  alkalies  retards  the  diastatic  or  amylolytic  action, 
but  the  caroid  shows  throughout  very  much  greater  amylolytic 
power  than  the  other  preparations. 

The  Ferments  of  the  Pineapple. — The  fruit  contains  very  active 
proteolytic  ferments,  its  juice  being  used  in  the  production  of  the 
artificial  predigested  beef  foods  by  a  prominent  American  firm. 
These  ferments  are  destroyed  by  boiling,  and  hence  are  no  longer 
active  in  the  preserved  fruit.  We  have  assured  ourselves  suffi- 
ciently of  the  proteolytic  activity  of  raw,  fresh  pineapple  juice  to 
recommen-d  it  in  achylia  or  subacidity,  and  to  forbid  its  use  in 
hyperacidity  and  hypersecretion,  as  well  as  in  gastritis  acida.  It 
is  allowed  mainly  because  of  its  pleasant  taste  and  because  it 
stimulates  desire  for  more  food.  The  fiber  must  be  removed  from 
the  mouth  and  not  swallowed  by  gastric  patients. 


CHAPTER  VII. 

SURGICAL  TREATMENT  OF  ORGANIC  GASTRIC  DISEASES. 

In  the  pre-antiseptic  time  the  stomach  was  regarded  as  a  "  Noli 
me  tangere."  Even  in  the  beginning  of  this  century  gastric 
wounds  were  considered  as  directly  fatal,  and  Larrey,  the  Surgeon- 
General  of  Napoleon,  was  one  of  the  first  to  declare,  "  Plaies  de 
I'estomac  ne  sont  pas  mortelles  dans  tous  les  cas  "  {cf.  Clinique 
Chirurg.,  tome  iv,  p.  lo),  which  was,  as  is  well  known,  confirmed 
by  the  notable  observations  of  our  countryman,  Beaumont  on 
Alexis  St.  Martin.  Not  only  were  surgeons  timid  about  the  almost 
unavoidable  peritonitis,  but  there  existed  a  universal  belief  that  the 
solving  and  peptonizing  action  of  the  gastric  juice  prevented  the 
wound  from  healing.  The  observation  that  undoubted  gastric 
ulcers  had  healed,  and  that  fistulse  produced  by  physiologists  in 
animals  healed  spontaneously,  and  that  gastrotomy  and  gastrostomy 
performed  in  pre-antiseptic  years  had  not  shown  the  corrosive  effect 
of  the  gastric  juice,— paved  the  way  for  experiments  by  Gussen- 
bauer  and  von  Winniwarter,  proving  that  gastric  wounds,  when 
sutured,  healed,  as  a  rule,  without  interference  from  any  digestive 
action  of  gastric  juice. 

The  first  proposition  to  treat  organic  gastric  diseases  by  operation 
was  made  by  Merrem,  who  originated  the  resection  of  the  pylorus 
(pylorectomy),  and,  after  performing  it  on  dogs,  suggested  it  for 
human  beings  (Dan'l  C.  Theodor  Merrem,  "  Animadversiones 
qusedam  chirurg.  experim.,"  etc.,  Giessse,  i8io). 

Gussenbauer  and  von  Winniwarter,  later  on,  demonstrated  that 
this  operation  was  technically  feasible,  and  that  removal  of  the 
pylorus  was  not  dangerous  to  life  [von  Langenbeck' s  Ardiiv,  Bd.  xix, 
S.  347)-  They  succeeded  in  showing  that  a  certain  per  cent,  of  cases 
of  pyloric  carcinoma  were  indications  for  this  operation.  Czerny 
and  Kaiser  confirmed  these  opinions,  and  the  latter  managed  to  heal 
and  keep  alive  a  dog  from  whom  he  had  almost  entirely  excised  the 
stomach.  As  a  surgical  curiosity,  Haberkant  {Arch.f.  klin.  Chirurg., 
Bd.  LI,  Heft  III,  S.  484)  mentions  a  total  extirpation  of  the  stomach 

336 


HISTORY    OF    GASTRIC    SURGERY.  337 

by  Dr.  Connor,  of  Cincinnati,  in  a  ^voman  fifty  years  of  age,  ^vho  died 
before  the  esophagus  could  be  united  to  the  duodenum.  Accord- 
ing to  Rydygier,  a  surgeon  named  Torelli,  in  1878,  executed  the 
first  gastric  resection  in  a  man,  removing  a  piece  16  cm.  long  that 
had  prolapsed  from  an  abdominal  stab  wound  {^Centralbl.f.  Chinirg., 
1879,  S.  398).  In  the  same  year  Billroth  brought  about  healing  of 
a  gastric  fistula  by  exposing  the  stomach  and  suturing  it  (JVie/i. 
nicd.  JVochenschr.,  1S81,  S.  275).  In  January,  1 88 1,  Billroth  exe- 
cuted the  first  successful  resection  of  the  p}-lorus  for  carcinoma. 

The  first  total  resection  for  ulcer  was  performed  b\'  Rydygier. 
and   the  first  partial  resection  for   ulcer  was   made  by  Czerny  in 

1882.  Both  were  successful.  Pean  executed  a  pyloric  resection 
in  1879,  before  Billroth,  and  so  did  Rydygier  in  1880,  but  both 
were  unsuccessful.  In  the  first  publication  of  Billroth's  resection 
[IVien.  ined.  Wochenschr.,  1881,  No.  6),  Wolfler  defined  the  limits  of 
the  usefulness  of  total  resection  as  existing  in  the  transition  of  the 
carcinomatous  tumors  to  the  pancreas  and  duodenum.  Cases  in 
which  the  carcinomatous  infiltration  extended  beyond  the  hepato- 
duodenal ligament  should  be  excluded  from  resection.  From 
these  indications  the  plan  to  a  second  operation  arose — "  gastro- 
enterostomy," which  is  a  type  of  entero-anastomosis  (Maisoneuve), 
an  artificial  communication  between  the  stomach  and  the  ieiunum, 
when  the  p}-loric  obstruction,  for  reasons  given,  can  not  be  removed. 
In  1881  (September  28th'),  Wolfler  performed  this  operation  for  the 
first  time.  But  the  very  next  case  (performed  by  Billroth')  was 
fatal,  the  patient  dying  with  constant  emesis  of  bile.  The  necropsy 
showed  that  the  upward  traction  of  the  jejunal  loop  had  caused 
what  is  termed  a  "spur,"' which  returned  the  duodenal  secretions 
(bile,  etc.)  into  the  stomach.  The  spur  had  divided  the  artificial 
gastro-intestinal  lumen  into  two  unequal  parts,  of  which  the  larger 
belonged  to  the  duodenal  canal,  the  smaller  to  the  jejunal  loop 
leading  away  from  the  stomach. 

As  a  necessary  result  of  this  the  bile  and  pancreatic  juice  ran 
into  the  stomach,  while  nothing  could  pass  out  into  the  diminutive 
discharging  outlet.  In  one  of  Lauenstein's  cases  ("  Verhandl.  d. 
Deutsch.  Gesell.  f  Chirurg.,"  Thirteenth  Congress)  the  mesentery 
of  the  jejunal  loop  which  had  been  drawn  up  to  meet  the  stomach 
compressed  the  transverse  colon.  The  adducent  part  of  the  loop 
was  drawn  across  the  colon  like  a  tense  ridge.     Courvoisier,  in 

1883,  invented  another  method  calculated  to  avoid  these  difficulties. 


^^!S         SURGICAL   TREATMENT    OF    ORGANIC    GASTRIC    DISEASES. 

Instead  of  inserting  the  jejunum  to  the  ventral  or  anterior  wall  of 
the  stomach,  he  made  a  slit  in  the  mesentery  of  the  transverse 
colon  and  inserted  the  loop  into  the  posterior  gastric  wall.  In 
order  to  secure  the  continued  onward  flow  of  the  bile  and  pancre- 
atic iuice  through  the  intestine,  Courvoisier  attached  the  adducent 
part  of  the  intact  loop  to  the  stomach  for  a  distance,  then  split  the 
abducent  part,  and  finally  sewed  the  wound  edges  of  the  gastro- 
intestinal opening. 

In  1885  von  Hacker  described  a  similar  but  much  more  im- 
proved method,  which  consists  in  the  following:  The  colon  and 
great  mesentery  are  raised  upward  ;  the  gaping  edges  of  the  slit  in 
the  mesocolon  are  attached  to  the  posterior  gastric  wall ;  finally, 
the  jejunal  loop  is  attached  to  the  stomach  within  this  slit  (von 
Hacker,  "  Verhandl.  d.  Deutsch.  Gesell.  f.  Chirurg.,"  1885,  Four- 
teenth Congress). 

A  third  method  of  gastro-enterostomy  was  suggested  by  Bill- 
roth and  Brenner  [Deufsc/ie  Zeitsc/ir. /.  Chirurg.,  Bd.  xxv,  p.  502).  In 
this  method,  openings  are  made  both  through  the  gastrocolic  liga- 
ment and  mesocolon,  through  which  the  jejunal  loop  was  drawn 
up  and  sewed  to  the  anterior  gastric  wall  immediately  above  the 
greater  curvature.  Von  Hacker  has  given  these  various  operations 
very  significant  and  explicit  Latin  designations  ("  Chir.  Beitr.  a.  d. 
Erzherzogin  Sophienspital  in  Wien,"  S.  42).  These  are  his  terms 
in  English  : 

1.  Gastro-enterostomy,  anterior,  antecolonic  (Wolfler). 

2.  Gastro-enterostom}'-,  posterior,  retrocolonic  (von  Hacker). 

3.  Gastro-enterostomy,  anterior,  retrocolonic  (Billroth-Brenner). 
A  number  of  other  modifications  must  be  passed  over,  since  we 

are  interested  only  in  the  clinical,  not  so  much  in  the  purely 
surgical,  aspect  of  the  subject. 

VARIOUS    FORMS   OF   OPERATIONS    PRACTISED   UPON   THE 

STOMACH. 

Gastrotomy  is  the  operation  of  opening  the  stomach  with  the 
object  of  removing  a  foreign  body;  then  sewing  up  the  wound  in 
the  stomach,  replacing  the  viscus,  and  sewing  up  the  external 
abdominal  wound.  This  operation  must  be  looked  upon  as  very 
successful,  for,  of  18  cases  reported  by  Henry  Morris  (Ashhurst, 
"  Encyclopedia  of  Surgery,"  vol.  v,  p.  589),  14  recovered. 

Gastrostomy  is  designed  to  rescue  a  person  from  immediate 


GASTROTOMY  AND  GASTROSTOMY. 


339 


starvation  when  there  is  a  stenosis  in  the  esophagus,  either  from 
cicatricial  contraction  resulting  from  esophageal  ulcer,  syphilitic, 
tuberculous  or  malignant  neoplasm,  or  corrosive  toxic  agents. 

The  same  causes  affecting  the  cardia — for  instance,  carcinoma  of 
the  cardia — may  necessitate  gastrostomy.  Our  experience  is,  that 
the  sooner  gastrostomy  is  performed  in  carcinoma  of  the  cardia, 
the  longer  is  the  possibility  of  life.  One  should  not  wait  until 
nothing  but  liquids  will  pass  the  stricture.  It  has  been  observed 
that  the  carcinoma  will  improve  and  show  some  tendency  toward 
healing  when  food  no  longer  passes  over  it  and  the  dilatation 
above  the  stricture  is  kept  clean  and  aseptic  b}'  esophageal  lavage. 
Whenever  possible,  the  dilatation  should  be  washed  out  daily,  even 
after  gastrostomy  has  been  performed.  In  cases  where  the  esoph- 
ageal stricture  had  become  impassable,  it  has  occasionally  been 
noticed  that  after  gastrosto*my  the  stenosis  again  became  permeable, 
and  food  could  be  swallowed  for  a  while.  Witzel  has  devised  an 
oblique  entrance  of  the  fistula  into  the  stomach,  making  use  of  the 
anatomical  relations  of  the  abdominal  walls  for  that  purpose.  The 
canal  is  laid  partially  in  the  gastric  and  partially  in  the  abdominal 
walls,  being  somewhat  tortuous,  and  mostly  closed  to  food  trying  to 
come  outward  (Witzel,  "  Z.  Technik  d.  Magenfistelanlegung,"  Cen- 
tralblattf.  CJiiriirg.,  1891,  No.  32).  Von  Hacker's  technic,  as  orig- 
inal with  him,  has  been  practised  in  a  number  of  cases  for  dilating 
esophageal  strictures  with  sounds  introduced  from  the  gastric  side, 
when  dilatation  of  the  strictures  from  the  mouth  had  failed.  The 
unfavorable  results  of  gastrostomy — Zesas  reported  only  19.5  per 
cent,  of  so-called  recoveries  in  131  operations  {ArcJi.f.  klin.  CJiiriirg., 
Bd.  xxxii) — are  largely  due  to  postponing  the  operation  until  the 
general  health  is  too  low  to  assist  in  recovery. 

Mikulicz  has  formulated  his  latest  results  in  the  following  table 
{^Arch.f.  klin.  Chmirgie,  Bd.  li,  p.  9,  1895) : 


GASTRECTOMY   AND    GASTROTOMY. 


Total 

Recovered. 

Died. 

Mortality 
Percentagf. 

For  simple  ulcer, 

For  ulcer  and  hemorrhage, 

For  ulcer  with  perforation, 

Occlusion  of  pylorus  with  a  gall-stone,  .    .    . 

I 

3 

I 
6 

i 

I 

I 
I 

0 
2 

I 

0.0 

66.66 
100. 0 
0.0 

Total, 

II 

3 

3 

50.0 

340 


SURGICAL   TREATMENT    OF    ORGANIC    GASTRIC    DISEASES. 


The  results  in  gastrostomy  for  esophageal  carcinoma  are  stated 
by  Mikulicz  (/^^  r//.)  as  follows:  Of  28  patients  that  survived  the 
operation  longer  than  three  weeks,  20  subsequently  died  of  the 
fundamental  disease.  The  shortest  duration  of  life  was  three  and 
one-half  weeks,  the  longest  twelve  months,  after  the  operation. 
The  average  duration  of  life  after  the  operation  was  four  and  one- 
half  to  five  months. 

GASTROSTOMY. 


Total. 

Recovered. 

Died. 

Mortality 
Percentage. 

Toxic,  corrosive  stricture  of  esophagus,     .    . 
Neurosis  (cardiospasm), 

9 
I 

34 

9 
I 

28 

0 
0 
6 

0.0 
0.0 

Carcinoma  of  cardia  or  esophagus,     .... 

17.64 

Total, 

44 

38 

6 

Gastrorrhaphy  is  an  operation  for  closure  of  wounds  of  the 
stomach. 

Pylorectomy,  or  Resection  of  the  Pylorus.* — In  considering 
the  value  of  this  operation  we  must  sharply  distinguish  between 
three  types : 

1.  Typical,  total,  or  circular  pylorectomy. 

2.  Atypical  pylorectomy,  which  consists  of  a  combination  of  the 
former  with  a  gastro-enterostomy. 

3.  Partial  pylorectomy. 

Typical  or  Total  Pylorectomy. — Indications  in  259  operations  were 
the  following:  Carcinoma,  215  times;  ulcer  or  cicatrix,  34  times; 
sarcoma,  twice ;  angioma  fibrosum,  once  ;  not  stated,  seven  times. 
In  judging  of  the  benefit  to  be  derived  from  these  operations,  we 
must  distinguish  sharply  between  (i)  the  immediate  and  (2)  the 
remote  results.  Generally  speaking,  surgeons  term  a  patient 
"  recovered  "  when  he  succeeds  in  getting  over  the  efifects  of  the 
operation  ;  this  is  the  immediate  result.  The  remote  results  are 
determined  by  the  duration  of  life  after  the  operation.  The  imme- 
diate results  of  the  259  cases  above  enumerated  are  the  following: 
Of  34  cases  of  benign  stenosis,  23  recovered;  of  215  cases  of  car- 


*  For  the  statistics  and  historical  information  on  the  subject  of  the  principal  operations 
we  are  indebted  to  an  article  by  Dr.  Haberkant  in  the  Arckiv  f.  klin.  CJiirurg.,  Bd.  LI, 
p.  861,  1896;  and  to  a  report  by  Prof.  J.  Mikulicz,  Archiv  f.  klin.  Chirurg.,  Bd.  Li, 
p.  9,  1895. 


PYLORECTOMY RESECTION    OF    THE    PYLORUS. 


HI 


cinoma,  98  recovered ;  both  cases  of  sarcoma  and  the  case  of 
angioma  fibrosum  recovered.  Haberkant  {loc.  cii)  found  the  mor- 
taUty  for  ulcer  to  be  34.4  per  cent.,  and  for  carcinoma,  56.7  per  cent., 
in  a  total  of  239  operations  performed  from  1879  ^^  1894.  It  is  a 
very  important  question  for  the  internist  whether  the  mortality  is 
becoming  less  as  time  progresses,  which  signifies  an  improvement 
in  the  technic  and  knowledge  of  the  subject.  Haberkant  arranged 
205  cases,  operated  on  from  1881  to  1894,  in  two  series  of  seven 
years  each  (from  1881  to  1888,  and  from  1888  to  1895).  In  the  first 
series  the  total  mortality  was  62.8  per  cent. ;  in  the  second  series  it 
was  45.1  per  cent.  For  carcinoma  a  reduction  of  the  rate  of  mor- 
tality from  65.4  per  cent,  to  42.8  per  cent.,  and  for  benign  pyloric 
stenosis  a  reduction  from  42.8  per  cent,  to  27.7  per  cent.,  is  calcu- 
lated. In  1882,  of  13  cases  of  resected  carcinomata,  all  died;  in 
1893,  of  eight  cases,  all  recovered.  There  may  be  some  objection 
to  the  absolute  correctness  of  these  figures,  but  they  undoubtedly 
admit  the  belief  that  our  methods  of  diagnosis  and  operative  technic 
are  improving.  Some  forms  of  gastric  cancer  are  much  more 
malignant  and  unfavorable  to  treatment  than  others.  In  44  cases 
in  which  microscopical  examinations  were  made,  we  found  the 
following  comparisons : 


Nature  of  thk  Gastric  Cancer. 

Number  of 
Operations. 

Recovered. 

Died. 

Scirrhus, 

Adenocarcinoma  (epithelial  carcinoma), 
Medullary  carcinoma, 

16 

10 

9 

9 

10 

5 

I 

7 

6 

S 
8 

Colloid  carcinoma,       

2 

44 

23 

21 

According  to  this  table,  colloid  carcinoma  is  the  most  favorable 
to  operation,  while  the  most  unfavorable  prognosis  is  to  be  formed 
of  medullary  sarcoma. 

The  remote  results  are  best  shown  in  the  duration  of  life  after  the 
operation,  which  is  expressed  in  the  accompanying  table  (see  end 
of  this  chapter),  from  which  it  is  evident  that  the  average  expecta- 
tion of  life  after  pylorectomy  for  carcinoma  is  not  very  long.  For 
of  26  so-called  recoveries,  or  immediate  good  results,  17,  or  nearly 
two-thirds,  died  within  one  year  after  the  operation.  Furthermore, 
of  26  (different)  cases,  12  died  in  from  one  and  one-half  to  thirteen 


342         SURGICAL    TREATMENT    OF    ORGANIC    GASTRIC    DISEASES. 

months  from  return  of  the  malignant  trouble  or  metastases.  One 
case  of  Billroth's  lived  five  and  a  quarter  years.  One  case  of 
Kocher  {Ccntralbl.  f.  Chir.,  1894,  S.  22 ij  lived  five  years  and  four 
months,  and  one  case  of  Ratimmow's  {ibid.,  S.  1014)  lived  eight 
years.  The  boundary  of  the  pathological  tissue  can  not  be  deter- 
mined accurately.  As  is  the  custom  in  most  malignant  neoplasms 
of  other  organs,  the  resection  is  made  by  cutting  through  .the 
apparently  or  visibly  healthy  tissue  one  cm.  from  the  limit  of  the 
diseased  portion.  Czerny,  however,  found,  by  careful  microscopical 
examination  of  resected  pieces,  that  the  edges  of  the  section,  made 
through  apparently  healthy  tissue,  contained  cancerous  alveoli ;  he 
therefore  advised  that  the  cut  be  made,  not  one,  but  three,  cm.  from 
the  limit  of  the  carcinomatous  tissue.  Virchow  holds  that  as  long 
as  a  neoplasm  is  solitary,  the  hope  for  a  successful  operation  must 
not  be  given  up. 

Pylorectomy  is  the  only  operation  which  can  make  a  definite 
cure  or  a  recovery  of  some  duration  possible  ;  and  although  the 
prospects  of  complete  cure  are  very  few,  we  must  hold  fast  to  the 
encouragement  which  statistics  furnish,  namely,  that  more  cases 
recover  with  improvement  in  the  technic  and  diagnosis.  Haber- 
kant  {loc.  cit.,  p.  26)  takes  too  gloomy  a  \^iew  of  the  future  of  gastric 
operations  when  he  asserts  that  we  must  expect  no  advance  in  the 
curability  of  gastric  carcinoma,  because,  in  his  opinion,  patients 
•decide  for  the  operation  too  late,  even  after  the  diagnosis  is  certain  ; 
and,  secondly,  because  it  will  be  impossible  to  diagnose  gastric  car- 
cinoma at  a  time  when  a  cure  by  extirpation  would  be  possible. 
The  early  diagnosis  of  gastric  carcinoma,  he  emphasizes,  is  in 
almost  all  cases  impossible.  The  surgeon,  as  a  rule,  concludes  to 
operate  only  when  distinct  stenotic  symptoms  are  present,  with 
emesis,  dilatation,  and  palpable  tumor.  The  only  sign  which 
Haberkant  cites  to  be  doubtful — that  is,  the  absence  of  HCl  in  the 
gastric  contents — is  by  no  means  the  only  one  the  clinician  has  to 
be  guided  by,  as  reference  to  the  chapter  on  diagnosis  of  gastric 
carcinoma  will  show. 

There  can  not  be  a  moment  of  doubt  about  the  feasability  of 
operation  when  gastric  dilatation  is  manifestly  due  to  palpable 
neoplasm,  even  if  it  were  not  malignant.  But  we  generally  advise 
operation  when  dilatation  is  associated  with  cachexia,  absence  of 
HCl  in  the  gastric  contents,  excess  of  lactic  acid,  and  presence  of 
the  Oppler-Boas  bacillus.     Stenotic  symptoms,  accompanied  with 


HOW    MANY    PYLORIC    NEOPLASMS    ARE    OPERABLE?  343 

these  signs,  are  indications  for  operation,  even  in  the  absence  of 
palpable  tumor. 

Exploratory  laparotomy,  which  Haberkant  states  to  be  the  only 
reliable  means  for  making  an  early  diagnosis  of  carcinoma,  should  be 
encouraged  by  the  internist,  not  because  carcinoma  can  be  diag- 
nosed with  certainty  thereby,  for  it  really  can  not,  as  the  stomach 
is  the  seat  of  many  kinds  of  neoplasms,  and  even  ulcer,  with  indu- 
rated edges,  may  simulate  carcinoma;  so  that  the  finding  of  a  new 
growth  does  not  include  a  knowledge  of  its  exact  nature,  and  if  a 
carcinoma  of  small  size  be  at  the  posterior  side  of  the  lesser  curva- 
ture, it  may  escape  attention  even  at  autopsies  until  the  stomach  is 
removed  from  the  body.  The  article  quoted  is  an  excellent  piece 
of  work,  and  the  pessimistic  view  on  the  future  development  of 
clinical  diagnosis  need  not  discourage  the  internist.  For  the 
progress  which  digestive  physiology,  pathology,  and  bacteriology 
have  made  in  the  last  twenty  years,  and  are  still  making,  strengthens 
the  belief  that  we  will,  in  the  near  future,  be  able  to  make  early 
diagnoses  of  gastric  neoplasms.  Whether  they  will  be  operable  or 
not  is  another  question,  concerning  which  the  internist  and  the 
surgeon  must  investigate  together. 

Even  after  the  diagnosis  is  certain,  much  foresight  is  necessary 
in  selecting  cases  for  operation;  the  establishment  of  the  indication 
must  be  done  with  exactness  and  care.  That  the  mortality  from 
cancer  resections  has  sunk  from  65.4  per  cent.,  in  the  period  from 
1879  to  1887,  to  42.8  per  cent,  in  the  period  from  1888  to  1894;  and 
of  benign  stenosis  from  42.8  per  cent,  to  27.7  per  cent,  in  the  same 
period,  shows  that  the  importance  of  exact  "  Indicationsstellung" 
is  being  appreciated. 

How  many  pyloric  carcinomata  are  operable?  In  the  records  of 
the  Vienna  Pathological  Institute,  from  1817  to  1873,  Gussenbauer 
and  von  Winiwarter  found  accounts  of  542  pyloric  cancers,  of  which 
223  were  entirely  isolated,  and  172  of  these  showed  no  adhesions  ; 
so  4 1. 1  per  cent  were  free  from  metastases,  and  37.7  per  cent,  were, 
in  addition  to  this,  free  from  adhesions — the  latter  were  suited  for 
resection.  In  many  of  the  instances  where  the  necropsy  showed 
adhesions,  there  must  have  been  a  time  when  they  were  not  present, 
so  that  a  big  field  for  operative  therapy  is  opened.  Streit  found,  at  the 
Bern  Pathological  Institute,  that  25.9  per  cent.  {^Deutsche  Zeitschr.  f. 
Chir.,  Bd.  xvi),  and  Kramer  (Konig,  "  Lehrb.  d.  spec.  Chir.,"  Bd.  11), 
that  33.3  per  cent.,  of  pyloric  cancers  were  operable.    The  best  sta- 


344         SURGICAL    TREATMENT    OF    ORGANIC    GASTRIC    DISEASES. 

tistics  State  that  from  one-quarter  to  one-third  of  these  neoplasms 
are  operable.  Adhesions  increase  the  mortality  ;  in  66  cases  of 
pylorectomy  in  which  records  were  kept  concerning  this  point, 
the  mortality  was  72.7  per  cent,  with,  and  27.2  per  cent,  without, 
adhesions.  No  immediate  recoveries  are  on  record  where  there 
were  adhesions  of  the  pylorus  with  the  transverse  colon,  or  with 
the  colon  and  the  pancreas  together.  Patients  with  tumors  of  the 
curvatures  and  fundus,  although  distinctly  ascertained  to  be  malig- 
nant, if  they  are  causing  no  stenotic  symptoms,  so  that  the  vicarious 
digestion  of  the  intestines  maintains  the  nitrogen  equilibrium  suffi- 
ciently, live  longer,  in  our  experience,  if  they  are  not  operated. 
That  is  to  say,  the  average  duration  of  life  after  the  date  of  exact 
diagnosis  was  longer  in  those  cases  of  this  type  that  were  not 
operated  than  in  those  that  were. 

Can  the  secretory  and  motor  function  be  restored  after  total  ex- 
tirpation of  a  malignant  tumor  ? 

Obalinski  and  Jaworski  {\Vien.  klin.  Wocliensclir.,  1889,  No.  5), 
Rosenheim  [Deutsche  ined.  Wochensclir.,  1892,  No.  49),  Kansche(z^/(^.), 
and  Zawadski  and  Sohnan  [Deutsche  ined.  Wocliensclir.,  1894,  No.  8) 
assert  that  secretion  is  not  restored  by  pylorectomy,  but  the  last  men- 
tioned authors  assert  that  the  motility  may  again  become  good.  In 
cases  that  are  operated  before  a  complete  destruction  of  the  gland- 
cells  has  taken  place,  the  lost  secretion  of  HCl  has  been  observed 
to  be  restored.  Rosenheim  [Berlin,  klin.  Wochenschr.,  1895,  No.  i) 
and  Boas  [Deutsche  med.  Wochenschr.,  1895,  No.  5)  have  reported 
the  only  two  cases  of  this  kind,  so  that  it  must  be  an  extremely 
rare  occurrence. 

Pyloric  stenoses  caused  by  simple  benign  adhesions  can  be  re- 
moved by  severing  the  constricting  bands.  These  adhesions  may 
cause  pain  and  hematemesis  without  gastrectasia,  as  was  shown  in 
a  case  of  Hahn's  [Deutsche  ined.  Wochenschr.,  1 894,  No.  43),  where  lap- 
arotomy revealed  five  adhesions  binding  the  stomach  to  the  colon. 
He  ligated  each  one  of  the  strong  bands  doubly  and  severed  it,  and 
from  that  moment  the  patient  recovered  perfectly.  Median  hernias 
of  the  linea  alba  have  been  known  to  cause  intense  gastric  suffer- 
ing, necessitating  operation.  Rosenheim  has  described  such  cases, 
which  were,  however,  much  benefited  by  lavage  and  diet,  so  that  the 
motor  insufficiency  was  much  reduced  [Berlin,  klin.  Wochenschr., 
1897,  No.  11).  Preperitoneal  lipomata  have  been  known  to  cause 
interference  with  the  motility  and  necessitate  surgical  interference. 


ATYPICAL    PYLORECTOMY.  345 

Adhesions  may  reunite  after  intersection  and  cause  renewed  trouble, 
as  was  shown  in  one  case  of  Hahn's,  in  which  the  adhesions  were 
divided  again  by  W.  Levy  two  years  after  the  first  operation  ;  a 
few  months  after  this  Hadra  executed  a  gastro-enterostomy,  on 
Rosenheim's  suggestion  {loc.  cit?j,  which  gave  no  perfect  relief,  as 
the  two  previous  operations  had  caused  new  adhesions.  Referring 
again  to  malignant  tumors  of  the  lesser  or  greater  curvatures 
where  good  motility  is  maintained,  and  that  cases  of  this  kind  which 
are  not  operated  live  longer  than  those  that  are,  we  might  add  the 
case  of  a  lady  in  whom  Musser  and  Da  Costa  diagnosed  a  palpable 
tumor  in  February,  1896.  Personally,  we  determined  the  location 
in  July,  1896,  when  there  was  complete  loss  of  all  secretion  and 
numerous  Oppler-Boas  bacilli  were  present  in  the  gastric  contents. 
A  fragment  of  the  neoplasm  was  obtained  in  September,  1896, 
during  lavage,  clinching  the  diagnosis.  With  daily  lavage  with 
HCl  solution  (4  :  1000),  highly  nutritious  and  concentrated  diet, 
rest,  and  internal  use  of  HCl,  condurango,  and  strychnin,  this 
patient  has  gained  12  pounds  in  six  months,  and  is  still  (September, 
1897)  able  to  take  walks  of  two  miles  a  day,  nineteen  months  after 
Musser  first  diagnosed  the  existence  of  a  gastric  tumor. 

The  number  of  authoritative  advocates  of  pylorectomy  for  benign 
stenosis  is  growing  less  and  less.  Von  Hacker  recently  again 
emphasized  that  gastro-enterostomy  is  not  used  enough  for  the 
treatment  of  cicatricial  stenoses  of  the  pylorus  and  duodenum,  and 
that  it  has  the  value  of  a  radical  operation  for  many  cases  without 
sharing  its  dangers  (von  Hacker, "  Magenoperationen,"  etc.,  etc.,  pub- 
lished by  William  Braumiiller,  Wien,  1895).  Mintz  considers  pylo- 
rectomy unjustifiable  for  benign  cicatricial  stenoses  [Zeitschr.  f.  klin. 
Med.,  Bd.  xxv).  For  mild  stenotic  cicatrices  the  pyloroplastic 
operation  has  proved  sufficient.  We  shall  refer  to  this  operation 
in  the  following. 

Atypical  pylorectomy  was  executed  first  in  1885  by  Billroth.  It 
is  a  combination  of  resection  of  the  pylorus  with  gastro-enteros- 
tomy recommended  in  cases  where  carcinomata,  although  operable, 
had  so  extensively  involved  the  gastric  walls  that  after  resection  it 
was  impossible  to  suture  the  remainder  of  the  stomach  to  the 
duodenum,  or  where  traction  upon  the  duodenum  to  meet  the 
stomach  would  produce  too  much  tension  upon  the  stitches. 

Von  Eiselsberg  executed  the  most  extensive  atypical  resection 
of  the  pylorus  in  a  very  large  but  sharply  limited  carcinoma.  His 
23 


346         SURGICAL    TREATMENT    OF    ORGANIC    GASTRIC    DISEASES. 

incision  began  close  to  the  cardia  and  descended  perpendicularly 
downward,  so  that  only  a  small  portion  of  the  left  fundus  remained 
{von  Langenbeck's  Archiv,  Bd.  xxxix).  Even  this  incision  was  not 
through  healthy  tissue,  and  the  stitches  tore  through,  termin- 
ating the  case  by  perforation  peritonitis.  In  20  cases  of  atypical 
pylorectomy  eight  died, — a  mortality  of  40  per  cent.  The  first  case 
of  immediate  success  by  Billroth  succumbed  to  a  recurrence  after 
four  months.  Kronlein  performed  this  operation  for  traumatic 
cicatricial  stenosis  extending  into  the  duodenum. 

Partial  Pylorectomy  and  Partial  Resections  of  tlie  Gastric  Walls. — 
The  indications  are  given  by  the  round  ulcer,  both  on  the  anterior 
and  posterior  walls,  cicatrices  that  produce  interference,  or  tumors 
of  the  neighborhood  that  have  extended  to  the  gastric  wall  without 
involving  the  entire  circumference  of  the  pylorus.  Partial  pylorec- 
tomy preserves  the  valvula  pylori,  which  is  itself  rarely  the  seat 
of  gastric  ulcer.  In  a  total  pylorectomy  the  sphincter  and  valve 
are  removed  entirely  and  replaced  by  a  gradually  contracting 
scar.  Haberkant  records  eight  such  partial  operations — three  by 
Billroth  (reported  by  von  Hacker,  loc.  cit)\  three  by  Czerny  {Beitr. 
z.  klin.  Chir.,^d.  ix,  1892);  one  by  Spear  {Centralbl.  f.  klin.  Chir., 
1885),  and  one  by  Schuchardt  (Twenty-third  German  Surgical  Con- 
gress, 1894). 

Billroth's  and  Spear's  cases  all  died  ;  the  three  cases  of  Czerny 
recovered.  The  indications  in  the  cases  of  the  first  two  surgeons 
were  :  cicatrices,  four  times  in  the  anterior  pyloric  wall.  The  indi- 
cations in  the  last  three  cases  by  Czerny  were  :  ulcer,  once ;  exten- 
sion of  sarcoma,  twice.  The  case  of  stenosing  ulcer,  operated  upon 
by  the  latter  by  this  method,  was  still  doing  well,  according  to  last 
reports,  ten  years  after  the  operation. 

The  case  of  Schuchardt's  is  most  instructive  in  bearing  out  our 
objection  to  Haberkant's  assertion  that  exploratory  laparotomy  is 
the  only  reliable  means  for  early  diagnosis  of  carcinoma.  Schuch- 
ardt's case  had  two  open  ulcers,  only  one  of  which  was  discov- 
ered when  the  stomach  was  opened,  located  at  the  lesser  curvature 
and  removed  by  excision  of  a  piece  as  large  as  a  25-cent  piece. 
Although  no  peritonitic  symptoms  appeared,  death  occurred  under 
progressive  cachexia  in  fourteen  days.  The  necropsy  showed  a 
second,  much  larger,  ulcer,  which,  in  Haberkant's  {loc.  cit.,  p.  514) 
own  words,  was  not  only  inoperable,  but  could  not  even  be  pal- 
pated.    If  a  very  large  ulcer  can  not  be  palpated  when  the  stomach 


GASTRO-EXTEROSTOMY.  34/ 

is  exposed,  exploratory  laparotomy  is  not  infallible  as  a  diagnostic 
method;  it  may  desert  us  like  our  clinical  methods,  and  is  much 
more  dangerous.  The  oldest  resections  of  the  gastric  zcall  are  by 
Billroth  {Wien.  med.  Wochenschr.,  1881,  p.  275)  and  Esmarch  (quoted 
by  Wolfler,  loc.  citi),  for  the  repair  of  fistulae, 

Rupp  resected  a  subserous  leiom}-oma  of  the  anterior  wall  near 
the  cardia  in  this  way  (von  Langenbeck' s  ArcJi.,  Bd.  xl,  p.  756). 
The  number  of  partial  resections,  including  both  those  of  the 
pylorus  and  of  the  anterior  gastric  wall,  amount  to  15  operations; 
eight  were  cured,  seven  were  fatal,  giving  a  niortah'ty  of  46.6  per 
cent. 

Gastro-enterostomy. — In  the  beginning  of  this  chapter  we 
have  described  the  various  (three  main)  t}-pes  of  this  operation  that 
have  been  suggested.  Which  of  these  types  of  operation — Wolf- 
ler's,  von  Hacker's,  or  Billroth-Brenner's — is  to  be  selected  is  a  matter 
to  be  decided  by  the  surgeon.  But  we  would  remark  in  parenthe- 
sis that  the  physiological  rotation  of  the  full  stomach  around  its 
long  axis,  whereby  the  large  curvature  is  turned  anteriorly  and 
the  smaller  posteriorly,  which  is  asserted  by  Tiedemann,  has  been 
confirmed  by  no  other  experimenter.  Betz  and  Lesshaft  [Virchozi'^s 
Arch.,  1882,  vol.  Lxxxvii)  have  opposed  the  view.  In  many  hundreds 
of  experiments  on  the  full  stomachs  of  animals  for  the  stud\-  of  the 
peristalsis  we  have  never  observed  it,  and  even  if  it  w^ere  observed 
when  the  abdomen  is  opened,  it  could  not  then  be  considered  phy- 
siological. The  hypothetical  gastric  rotation  has  been  adduced  as 
an  objection  to  Wolfler's  anterior  antecolonic  operation,  on  the 
ground  that  the  artificial  lumen  between  stomach  and  intestine  was 
compressed  by  bringing  the  loop  between  the  abdominal  wall  and 
the  stomach  during  this  rotation.  \'on  Hacker's  method  does 
avoid  spur  formation,  and  thereby  retroflux  of  duodenal  contents 
into  the  stomach,  and  also  compression  of  the  transverse  colon  b}- 
the  inserted  jejunal  loop.  In  addition  to  this  the  entire  intestinal 
canal  remains  unchanged  in  its  natural  anatomical  relations.  \'on 
Hacker  himself  states  that  the  mortality  is  not  materially  reduced 
by  his  method.  The  functional  results  are  claimed  by  most  Ger- 
man surgeons  to  be  better  with  von  Hacker's  operation. 

Results. — In  388  cases  Haberkant  found  the  total  mortality  to  be 
41.5  per  cent.  For  gastro-enterostomy  for  carcinoma  it  was  43.5 
per  cent.  ;  for  ulcer,  25.5  per  cent.  One  of  the  indications  of  gastro- 
enterostomy is  the  simple  atonic  dilatation.     Four  such  operations 


348         SURGICAL   TREATMENT    OF    ORGANIC    GASTRIC    DISEASES. 

are  reported,  one  of  which  (Selenkow)  died  and  the  remaining 
three  (Renton,  von  Kleef,  and  Jeannel)  recovered  and  the  func- 
tional result  was  good.  Concerning  the  remote  results,  it  is  self- 
evident  that  in  carcinoma  they  can  not  be  of  long  duration,  as  the 
growth  is  left  intact;  nevertheless  the  table  at  the  end  of  this  article 
shows  ten  cases  in  which  the  recovery  lasted  over  a  year.  A  singular 
gastro-enterostomy  is  that  reported  by  Hahn  {Berlin,  klin.  Wochen- 
schr.,  1894,  p.  1097).  The  operators  were  convinced  that  the  neo- 
plasm was  a  carcinoma  ;  the  patient  lived  seven  years  after  the  oper- 
ation without  complaints,  the  tumor  always  being  palpable.  This 
case  will  always  remain  a  doubtful  one. 

Robert  F.  Weir  has  attempted  to  prove  statistically  that  gastro- 
enterostomy keeps  patients  with  pyloric  carcinoma  alive  as  long  as 
pylorectomy,  whereas  the  mortality  is  in  the  proportion  of  12  per 
cent,  for  the  former  to  52  per  cent,  for  pylorectomy. 

Haberkant's  statistics  of  a  much  larger  number  of  cases  shows 
a  mortality  of  54.4  per  cent,  for  resection  to  43.5  per  cent,  for  gas- 
tro-enterostomy. But  then  many  cases  have  formerly  been  resected 
that  would  in  the  present  advanced  state  of  knowledge  not  have 
been  operated.  Pylorectomy  gives  a  better  prospect  for  more  last- 
ing recovery  than  gastro-enterostomy.  Of  47  cases  recovered  from 
pylorectomy,  22  lived  longer  than  one  year  after  the  operation  ;  but 
of  58  cases  of  gastro-enterostomy,  only  12  lived  longer  than  one 
year.  With  the  exception  of  Hahn's  doubtful  case,  there  is  no 
gastro-enterostomy  in  which  the  recovery  lasted  longer  than  two 
years  ;  but  of  Haberkant's  collected  successful  pylorectomies,  12 
lived  longer  than  two  years. 

Pyloroplastic  Surgery  (Pyloroplasty). — This  operation  was 
first  devised  by  von  Heinecke,  in  March,  1886.  The  first  operation 
was  a  success.  In  February,  1887,  Mikulicz  rediscovered  and 
applied  the  method  independently  of  von  Heinecke.  The  operation, 
which  is  applicable  to  some  pyloric  cicatrices,  is  carried  out  by 
slitting  open  the  scars  longitudinally  in  the  line  of  the  pyloric 
lumen  and  pulling  the  wound-edges  apart  by  hooks  inserted  in  the 
middle;  then  they  are  reunited  by  sutures  transversely.  Graphi- 
cally the  procedure  is  expressed  thus: 

AC 
a ^  ^  ^  ^ 


DIGITAL    DIVULSION    OF    THE    PYLORUS.  349 

Cases  have  been  reported  in  which  pyloroplastic  surgery  was 
attempted,  and,  failing,  a  pylorectomy  had  to  be  done  (Lobker,  "  Ver- 
handl.  des  XXI.  Deutsch.  Chir.  Kongresses,"  i,  60).  Czerny  reported 
a  case  in  which  resection  had  to  be  done  because  the  scar  was  so 
rigid  it  could  not  be  unfolded  [Beitrdge  z.  klin.  Chir.,  Bd.  ix,  1892, 
p.  678).  The  cases  that  recover  from  a  successful  operation  of 
this  kind  are,  as  a  rule,  cured  permanently  ;  no  return  of  pyloric 
stenosis  has  been  reported. 

Up  to  1894  (inclusive),  51  operations  of  this  type  have  been  com- 
piled, 40  of  which  were  successful  and  11  fatal,  making  a  mortality 
of  21.5  per  cent.  In  44  instances,  where  the  indication  was  stated, 
there  were  seven  peptic  ulcers  and  37  cicatricial  stenoses;  but  of 
these  37  scars,  14  were  produced  by  corrosive  poisons. 

Digital  Divulsion  of  the  Pylorus. — Loreta's  operation  consists 
of  a  simple  gastrotomy  and  subsequent  gradual  expansion  of  the 
pylorus,  by  introducing  first  one  and  then  two  fingers ;  the  dilat- 
ing forceps  has  been  used  for  the  same  purpose.  The  dangers  of 
the  procedure  consist  in  [a)  rupture  or  production  of  hemorrhages 
by  lesions  of  the  gastric  wall,  {t>)  frequent  return  of  the  stenosis. 

According  to  Bull  {Centralbl.f.  CJiir.,  1890,  S.  149),  Loreta  himself 
has  had  the  return  occur  in  three  cases.  Haberkant  {loc.  cit.)  has 
compiled  31  cases  of  Loreta  operations,  with  19  cures  and  12 
deaths — a  mortality  of  38.7  per  cent.  Three  of  the  fatal  operations 
were  for  carcinomata. 

Novara  had  to  execute  a  resection  after  divulsion  had  failed  ;  the 
only  justifiable  indication  is  cicatricial  stenosis.  The  operation  has 
few  advocates,  and  will  have  to  give  way  to  more  exact  and  reliable 
operative  methods. 

For  atonic  forms  of  dilatation  that  resist  all  medical  treatment, 
Heinrich  Bircher  (of  Aarau,  Switzerland)  has  devised  a  new  opera- 
tion, called  gastroplication.  This  surgeon  attempted  to  improve 
the  motility  of  the  stomach  by  a  reduction  of  its  size  through 
making  a  fold  or  plait  in  the  gastric  wall.  The  greater  curvature 
is  raised  to  a  much  higher  level  by  this  operation.  Bircher  ob- 
tained good  results  in  three  cases,  one  of  which,  however,  died  three 
months  after  the  operation.  A  certain  amount  of  muscular  tonicity 
must  still  be  left  in  order  to  make  this  operation  even  a  partial 
success  {American  Jour.  Med.  Sciences,  1892,  vol.  cm,  p.  333). 
The  operation  has  not  as  yet  been  repeated  in  a  sufficiently  large 
number  of  cases  to  permit  of  a  correct  judgment  of  its  real  value. 


350         SURGICAL    TREATMENT    OF    ORGANIC    GASTRIC    DISEASES. 

The  Fundamental  Factors  Influencing  the  Rate  of  Mor- 
tality in  Gastric  Operations, — These  are  partly  under  the  control 
of  the  physician  and  partly  not.  Those  over  which  we  may  exer- 
cise control  are  (I)  defects  in  the  technic,  (II)  selection  of  the 
kind  of  operation,  (III)  duration  of  the  operation. 

The  factors  that  escape  control  are  (I)  age  of  the  fundamental 
disease,  (II)  nature  and  extent  of  this  disease,  (III)  age  of  the 
patient. 

A.  Factors  Under  the  Control  of  the  Surgeon. 

I.  Faults  in  the  tecJinic,  as  a  rule,  lead  to  peritonitis,  of  which  one 
must  distinguish  two  kinds  :  {a)  The  septic,  produced  by  infection 
during  the  operation ;  and  (^)  perforation  peritonitis,  due  to  a 
technical  defect  in  placing  the  sutures.  Perforation  peritonitis  as 
a  result  of  insufficiency  of  the  sutures  is  much  more  common  in 
pylorectomy  than  in  gastro-enterostomy,  because  the  lines  of  suture 
are  much  longer.  However,  peritonitis  may  be  caused  by  errors 
in  diet  or  by  spontaneous  perforations  in  other  parts  of  the  stom- 
ach, independently  of  the  technic.  In  165  fatal  issues,  with  autop- 
sies, the  cause  of  death  was  peritonitis  in  one-fourth  of  the  cases; 
only  three  fatal  cases  were  due  to  spontaneous  peritonitis. 

II.  llie  selection  of  the  proper  operation  for  any  particular  case  is 
facilitated  by  an  exact  definition  of  the  indications. 

The  indications  for  pylorectomy  are  :  (i)  the  operable  carcinoma 
or  sarcoma,  (2)  the  peptic  stenosing  ulcer  or  cicatrix,  (3)  perfora- 
tion from  pyloric  ulcer. 

The  contra-indications  are  : 

(i)  {a)  Firm  adhesions,  especially  posteriorly  on  account  of 
danger  of  injuring  the  hepatic  artery  and  vein,  {6)  adhesions  with  the 
pancreas,  (i:)  with  the  liver,  (^)  with  the  meso-  and  transverse  colon. 

(2)  Infiltration  of  lymphatic  glands  [a)  of  the  lesser  omentum, 
{b)  posterior  surface  of  the  stomach,  {c)  of  the  porta  hepatis. 

(3)  Icterus  from  metastases  or  compression  by  the  tumor. 

(4)  Great  exhaustion  of  the  patient. 

Severe  gastric  heniorrliage  can  be  treated  in  most  cases  by 
internal  medication.  Gastric  ulcers  that  have  given  rise  to  repeated 
grave  hemorrhages  have  been  successfully  excised  by  Czerny 
(Archivf.  klin.  Chir.,  1884),  Cordua  (quoted  in  Debove  and  Remond, 
"  Traite  de  Mai.  de  I'Estomac "),  and  Mikulicz  {Deutsche  med. 
Wochenschr.,  1892). 

Dunin  asserts  that  ulcers  in  the   pyloric  region  causing  serious 


INDICATIONS  FOR  PYLORECTOMY  AND  GASTRO-ENTEROSTOMY.    35  I 

hemorrhages  would  heal  rapidly  if  the  pyloric  passage  were  put  at 
rest  by  a  gastro-enterostomy  (]\Iintz,  loc.  cit^. 

Kiister  cured  persistent  hematemesis  from  pyloric  ulcer  on  the 
posterior  wall  by  opening  the  anterior  wall,  producing  scabbing  in- 
crustation with  the  thermocautery,  and  making  a  wide  gastro-enter- 
ostomy. During  the  operation  a  cherry-stone  was  extracted  from 
the  depth  of  the  ulcer.  ]Mikulicz  did  a  pyloroplastic  operation  for 
uncontrollable  hemorrhage.  The  gastro-enterostomy,  after  cicatriz- 
ing the  ulcers  with  the  thermocautery,  is  generally  a  prophylactic 
measure  to  forestall  a  prospective  pyloric  stenosis.  A  pyloroplastic 
operation  may  accomplish  the  same  object. 

For  perforation  of  gastric  ulcer  many  operations  have  been  exe- 
cuted. Pariser  has  recently  reported  43  such  operations  with  33 
deaths  and  ten  recoveries.  Only  in  four  cases  was  the  perforation 
in  the  pylorus  (Pariser,  Deiitsche  vied.  Wochenschr.,  1895).  N.  Senn 
suggested  gastric  distention  with  h}-drogen,  in  order  to  rapidly  find 
out  the  seat  of  the  perforation. 

Indications  for  gastro-enterostomy  : 

(i)  Pyloric  carcinoma  with  extensive  adhesions  and  glandular 
metastases.  Frequently  it  is  not  decided  to  do  a  gastro-enteros- 
tomy until  the  abdomen  is  opened;  a  resection  has  often  been 
planned,  but  had  to  be  replaced  by  a  gastro-enterostomy.  If  the 
posterior  wall  alone  is  free  from  infiltration,  von  Hacker's  method  is 
indicated;  in  the  reverse  case,  the  methods  of  Wolfler  or  Billroth- 
Brenner. 

(2)  Stenosing  ulcer  {a)  both  when  the  pylorus  is  still  isolated 
and  free,  and  {b)  when  it  is  adherent  with  its  surrounding.  With 
this  indication  pylorectomy  is  unjustifiable,  but  partial  resection 
and  pyloroplastic  surgery  may  yet  compete  with  gastro-enteros- 
tomy. When,  however,  a  cicatricial  pyloric  stenosis  extends  into 
the  duodenum,  nothing  but  a  gastro-enterostomy  should  be 
done. 

(3)  Stenoses  in  the  duodenum  outside  of  the  pylorus.  Four 
operations,  with  three  recoveries,  have  so  far  been  executed  for  this 
indication, 

(4)  Stenoses  by  neoplasms  of  neighboring  organs — the  gall- 
bladder, periportal  lymphatic  glands,  and  pancreas.  Novarro  per- 
formed a  gastro-enterostomy  for  pyloric  stenosis  caused  by  echino- 
coccus  cyst  of  the  liver  [Deutsche  vied.  Wochenschr.,  1891,  No.  4, 
S.  152).     Stansfield  did  the  same  operation,  with  good  result,  for 


352         SURGICAL   TREATMENT    OF    ORGANIC    GASTRIC    DISEASES. 

tumor  of  the  pancreas  {Brit.  Med.  Jour.,  1890,  pp.  294  and  1300), 
making  use  of  Senn's  bone-plates. 

(5)  Purely  functional  dilatation  due  to  atony  of  the  musculature 
without  pyloric  stricture.  Four  gastro-enterostomies  for  this  indi- 
cation are  on  record.  Recently,  Bircher  has  proposed  gastroplica- 
tion  (resection  of  a  fold  of  the  stomach-wall)  for  this  purpose. 

III.  The  Duration  of  Gastric  Operations. — It  is  evident  that  the 
sooner  an  operation  is  completed  the  less  the  danger  of  shock  and 
sepsis.  With  the  view  of  shortening  the  time  of  operation, 
Rydygier  and  Lauenstein  advised  the  employment  of  continued 
sutures,  which  they  claim  abbreviate  the  time  by  one  hour. 
The  most  celebrated  time-  and  labor-saving  devices  in  gastro- 
intestinal surgery  are  by  our  countrymen.  Murphy  and  Senn.  The 
advocates  of  Senn's  bone-plates  have  claimed  that  the  mortality 
under  the  older  suture  methods  was  from  42.8  per  cent,  to  47 
per  cent.  (Herbert  Page  and  von  Hacker),  and  in  41  operations  by 
the  Senn  method  the  mortality  was  only  24,5  per  cent. 

The  decalcified  bone-plates  of  Senn  are  not  always  digested.  In 
one  of  the  inventor's  own  cases  they  were  vomited  undigested 
forty  hours  after  the  operation.  Haberkant  asserts  that  the  advan- 
tage of  the  saving  of  time  is  counterbalanced  by  less  safety.  For 
surgical  opinions  on  the  Murphy  button  and  Senn  plates  we  must 
refer  to  journals  and  text-books  on  abdominal  surgery.  But  so 
much  is  clear :  shortening  of  the  time  of  operations  by  these  con- 
trivances is  a  great  gain. 

B.  Factors  that  Escape  Control. 

I.  Age  of  the  Underlying  Disease. — This  can  not  be  determined 
statistically,  for  both  ulcer  and  carcinoma  may  remain  latent  for 
months,  and  it  is  impossible  to  ascertain  the  age  of  these  conditions 
at  the  autopsy.  We  have  observed  a  large  carcinoma  in  a  white 
woman  who  died  at  Bay  View  Hospital,  occupying  the  posterior 
gastric  wall,  when  during  life  there  had  been  no  gastric  symptoms. 
Osier's  case  of  very  rapid  course  in  gastric  carcinoma — two  weeks 
from  the  onset  of  severe  dyspeptic  symptoms — made  it  plain  at  the 
autopsy  that  the  growth  had  been  of  considerable  duration,  but 
had  for  a  long  time  not  undermined  the  patient's  health  [Univ. 
Medical  Magazine,  January,  1895).  The  anamnesis  given  by 
patients  regarding  the  period  since  when  they  have  suffered  from 
dyspepsia  is  frequently  unreliable.  The  earlier  the  case  is  pre- 
sented for  operation  the  more  favorable  the  prospects. 


EFFECT  OF  AGE  ON  THE  OPERATIVE  RESULT.        353 

II.  Nature  and  Extent  of  the  Fundamental  Gastric  Disease. — Con- 
cerning this  point  the  statistics  show  that  the  mortality  in  pylo- 
rectomy,  as  well  as  in  gastro-enterostomy,  is  greater  for  carcinoma 
than  for  ulcer.  Under  the  head  of  contraindications  to  these  opera- 
tions we  have  dwelt  upon  the  dangerous  influences  of  the  extent  of 
the  disease. 

III.  Effect  of  the  Age  of  the  Patie^tt. — In  the  cases  as  they  are  pre- 
sented for  operation  there  are  so  many  other  governing  factors  that 
the  matter  of  age  does  not  appear,  from  statistics,  to  exert  much 
influence  on  the  result  of  these  operations,  provided  the  other  con- 
ditions previously  mentioned  are  favorable.  A  difference  becomes 
noticeable  when  the  age  is  over  sixty  years.  Among  176  resections, 
the  percentage  of  mortality  of  those  under  fifty  years  was  50.4  per 
cent.,  and  of  those  over  fifty  years,  52.9  per  cent.  With  gastro- 
enterostomy the  rate  was  42.4  per  cent,  for  those  under  fifty 
years,  and  57.7  per  cent,  for  those  over  fifty.  These  statistics, 
therefore,  do  not  confirm  a  marked  influence  of  age  on  the  rate 
of  mortality. 

A  critical  consideration  of  these  factors,  in  connection  with  other 
elements  before  mentioned,  justifies  the  hope  that  diagnosis  and  gas- 
tric surgery  have  not  reached  their  highest  development  as  yet,  and 
we  may  expect  a  further  lowering  of  the  rate  of  mortality. 

An  artificial  communication  between  the  stomach  and  intestines, 
as  is  performed  in  gastro-enterostomy,  may  become  much  smaller 
by  cicatricial  contraction.  Kocher  has  reported  two  such  observa- 
tions. In  one  case  Czerny  made  an  opening  three  cm.  in  diameter; 
at  the  autopsy,  five  months  later,  it  had  contracted  down  to 
eight  mm. 

Heinsheimer  has  made  careful  analytical  observations  on  the 
metabolism  in  two  cases  of  gastro-enterostomy  ("  Mittheilungen 
a.  d.  Grenzgebieten  d.  Medizin  u.  Chirurg.,"  Bd.  i,  S.  350).  In  this 
piece  of  work,  which  was  done  under  von  Noorden,  Rachford's  ob- 
servation that  fats  require  a  very  thorough  and  intense  mixture 
with  the  secretions  of  the  pancreas  and  liver  for  their  digestion 
{Centralbl.  f.  Pliys.,  1896,  Heft  4)  was  confirmed.  The  further  away 
the  gastro-intestinal  communication  is  laid  from  the  duodenal 
orifices  of  these  glands,  the  more  defective  the  fat  digestion  and 
resorption.  It  is  therefore  suggested  that  in  gastro-enterostomies 
a  jejunal  loop,  as  near  as  possible  to  the  duodenum,  be  anastom- 
osed with  the  stomach. 


354 


SURGICAL    TREATMENT    OF    ORGANIC    GASTRIC    DISEASES. 


Gastro-anastomosis  is  an  operation  first  performed  by  Wolfler 
for  hour-glass  stomach,  by  which  one  portion  of  the  organ  is  anas- 
tomosed with  the  other  at  the  greater  curvature.  Gastro-anasto- 
mosis remedies  the  separation  of  the  organ  into  two  distinct  cavities 
separated  by  a  narrow  isthmus.  Von  Hacker  reports  and  pictures 
cases  of  hour-glass  stomachs  complicated  with  cicatricial  pyloric 
stenosis,  for  which  he  recommends  a  double  operation — either  a 
pylorectomy,  or  a  pyloroplastic  operation  with  gastro-anastomosis, 
or,  best,  a  gastro-enterostomy  and  gastro-anastomosis  (von  Hacker, 
"  Magenoperationen,"  etc.,  Wien,  1895). 

For  benign  stenoses  of  the  pylorus,  pylorectomy  is  more  and 
more  deserted  in  favor  of  gastro-enterostomy,  which  gives  the  same 
functional  results  without  the  dangers  (Ernst  Siegel,  "  Mittheil.  a.  d, 
Grenzgebieten  d.  Medicin  u.  Chir.,"  Bd.  i,  p.  347). 


DURATION  OF  LIFE  AFTER  RESECTION  IN  51  CASES  OF  CARCINOMA 
OF  ?YLORUS.—{f/aderMn/.) 


0 

! 

b 
0 

Death. 

a  '{I 

Cause  of  Death. 

LiviNCx  AT  Date 

§=3 

OP  THIS  Report. 

§  < 

So 

2; 

z 

After  I  "4  months, 

I 

Return  of  cancer. 

After  2  months, 

I 

"      2           " 

3 

One  of  metastasis  in  the 

"      3 

I 

liver. 

"      3J4     " 

I 

"       2/,         " 

I 

Acute  lung  disease,  no  re- 

"     4 

I 

turn  and  no  metastasis. 

"      6 

I 

<'       4 

2 

Return. 

i     "      7K     " 

I 

"    5 

2 

One  of  lobular  pneumonia. 

1     "      8 

I 

one  of  chronic  pyemia. 

1     "      9 

I 

'     6 

2 

One    of    return,    one    of 
cicatricial  stenosis. 

"      I  year,  . 
"      I  year  and 

2 

'     6/^      " 

I 

Return. 

2  months, 

I 

"     7 

2 

"      i^  years, 

I 

"     8 

I 

Return. 

"      2           " 

2 

"     10        " 

I 

Return. 

"      2  years  and 

"     II  i<     " 

I 

Rectal  and  pelvic  carci- 

!              2  months, 

2 

noma. 

"      2j4  years. 

I 

"     I  year,  .    . 

3 

Two  return. 

"      almost   3 

"     13  months, 

2 

Return. 

years,   . 

I 

"      iX  years. 

I 

Return. 

"      3K  years, 

I 

"       2/,         " 

I 

"      5  years  and 

"     3 

I 

Cicatricial  stenosis. 

4  months, 

I 

Kocher. 

"     5X     " 

I 

Not  stated  (Billroth). 

Over  8  years,  .    . 
Total,  .    .    . 

I 
21 

Ratimraow. 

Total,  .    .    . 

26 

OPERATIVE   STATISTICS. 


355 


RECOVERIES   AND    DEATHS:     PERCENTAGE    OF   MORTALITY    IN 
CASES  OF  RESECTION  OF  FY'LORVS.—{Ilaier^afit.) 


579 


Name     of 
Operator. 


Result. 


Carci- 
noma. 


Ulcer 

-      AND 

Cica- 
tricial 
Steno- 
sis. 


Sar- 
coma 

AND 

Myoma. 


No  Indi- 
cation 
Stated. 


Remarks. 


1885  I  Rydygier,     . 

1885  :  Gussenbauer, 

1889  [  Augerer,  .    . 

1890  I  Billroth,    .    . 


Lauenstein, 
Novarro, 
Tillmans, 
V.  Heinecke, 
Schonborn,  . 
Roux,   .    .    . 


Doyen, 

Lobker, 
Schede, 
von  Kleef. 
Kraske, 
Czerny, 


Kocher, 


Kronlein, 
l8p4  ^  Kappeler, 


Mikulicz, 

Other  cases, 
exclusive  of 
above,     .    . 


14 


166 


15 


79 


87 


13 


60 


Total, 


76 


379:191  188  130  145  32    20 


Sar- 
coma 


Sar- 
coma. 


Of  these,  thirty-six 
w^ere  total  resec- 
tions ;  3  partial,  2 
atypical  pylorec- 
tomies. 


One  atypical,  the 
rest  typical,  total 
resections. 

All  atypical  pylorec- 
tomies. 


Three  partial  re- 
sections, the  rest 
typical,  total  pylo- 
rectomies. 

In  all  9  cases 
Kocher  used  his 
method  with  fol- 
lowing gastro- 
duodenostomy. 

Total  mortality, 35. 7 
per  cent.  For  car- 
cinoma alone,  38. 1 
per  cent. 


Of  these,  147  were 
total  resections  ; 
17  atypical,  and  2 
partial,  pylorec- 
tomies. 


24 


23 


RESULTS  WITH  GASTRO-ENTEROSTOMY  FROM  1885  TO  1893. 


< 

J 

Ulcer  and 

u 

X 

Result. 

H 

Ca 

RCINOMA. 

Cicatricial 

^ 

-J     . 

Stenosis. 

s 

0  . 

^S 

0 

Author. 

0  0 

•d 

•a 

i 

•a 

0^ 

OS  H 

aj 

1         >>4J 

e 

.'^^ 

OS 

a 
a 
g 

3 

> 
0 
0 

•a 

(5 

0 

•a 

Q 

> 
0 

•a 
Q 

5  " 
0  S 

> 

Z 

Pi 

H 

« 

,  §"- 

« 

S*^ 

1885 

Kramer,     .... 

20 

8 

12 

S 

II 

68.7 

3 

I 

1886 

Saltzmann,    .    .    . 

23 

6 

12 

66.6 

1887 

Rockwitz,      .    .    . 

29 

16 

13 

44.8 

II 

12 

s 

I 

, 

1890 

Xovarro,       .    .    . 

.s.s 

24 

43-6 

1890 

Mehler,     .... 

55-1 

.     . 

S8.8 

.  . 

.    -'38.5 

189I 

Page, 

36 

IS 

41.6 

1892 

Hadra, 

76 

33 

43 

S6 

1893 

Zeller, 

152 

.•  . 

86 

66 

43-4 

391 

24 

64 

141 

144 

8 

2 

RESULTS  OF  VARIOUS  OPERATORS  WITH  GASTRO-ENTEROSTOMY. 

[Habey-kantS) 


Year 

of 
Publi- 
cation. 

Operator. 

in    . 

Carci- 
noma. 

Ulcer 

AND 

Cica- 
tricial 
Ste- 
nosis. 

Dilata- 
tion 
of  the 
Stom- 
ach. 

Sar- 
coma. 

No  Indi- 
cation 
Stated. 

Remarks. 

B  < 

■6 

> 
a 

V 

Qi 

Q 

P 

> 
0 

u 

•d 

5 

•d 

> 

0 
0 

•d 

6 

•d 

> 
0 

•d 

5 

■d 

> 
0 
0 
u 

a 

•d 

V 

5 

1887 
1890 
1890 
189I 
1891 
189I 

189I 

189I 
1893 

1893 

1893 
1893 

1893 
1893 

1894 
1894 

Liicke,      .    . 
Billroth,    .    . 
Novarro,  .    . 
I^auenstein,  . 
Hahn,  .    .    . 
Bowreman- 
Jesset,  .    . 
Senn,    .    .    . 

Remedi,   .    . 
Roux,    .    .    . 
Doyen,      .    . 

von  Kleef,    . 
Codivilla, 

V.  Heinecke, 
Lobker,    .    . 

Czemy, 

Kraske ,    .    . 

Other  cases, 
exclusive  of 
above,     .    . 

Total,    .    . 

8 
28 
10 

17 
II 

5 
13 

6 

14 
10 

19 
6 

6 

7 

23 
10 

195 
388 

5 
14 

5 
10 

7 

2 

4 

4 

12 

7 

66 
136 

I 

14 

3 

3 

3 

7 

2 

3 

7 
3 

59 
105 

2 

2 
2 

3 

4 

2 
20 

35 

2 

I 
9 

12 

I 

2 

3 

I 
I 

I 
I 

I 

I 

5 

3 

4 

• 
6 

13 

• 

21 

52 

6 

2 
9 

4 
5 

• 

16 

42 

Calculated  according 
to  Czemy. 

Two  carcinomata,  8 
cicatrices. 

Operated  in  one  year 
by  von  Hacker '  s 
method. 

All  according  to  von 
Hacker's  method. 

356 


OPERATIVE    STATISTICS. 
DURATION  OF  LIFE  AFTER  GASTRO-ENTEROSTOMY 


357 


Death. 


After  I     month,    . 
"      l^  months, 


4 
6 

lo 

I  year, 
I  year  and  2  months 
li^  years,      .    .    .    , 
I  year  and  7  months 
I     "      "8        " 
I      "       "  lO        " 


Total, 


Number 

OF 

Cases. 


42 


Living  and  at  the  Time  of 
Report  in  Good  Health. 


After  2  months. 


7 
9 


1  year  and  ii  months, 

2  years, 


Total, 


Number 

OP 

Cases. 


i(Hahn). 


i6 


EFFECT  OF  AGE  ON  THE  RESULT  OF  VARIOUS  GASTRIC  OPERA- 
TIONS.—(i%(^^r/^««/.) 


Total  Typical 
Resection  op 

Gastro-enteros- 

Atypical  R 

ESEC- 

Pyloroplastic 

TOMY. 

tion  OF  Pylorus. 

Operation. 

Pylorus. 

Age 

0  f. 

•0 

•u 

0  g 

Si  ° 

T3 

-0' 

0- 
S.2 

■y 

•a 

J-..2 

-d 

i" 

> 

•2  « 

> 

-2  « 

> 

c  « 

> 

1=  0 

0 

0 

B  2 

H 

0 

S    J; 

P 

E  u 

Q 

^^ 

Pi 

^0 

Pi 

^'^ 

Pi 

20  years. 

2 

2 

I 

I 

2 

2 

22-30      ' ' 

9 

6 

3 

21 

14 

7 

3 

I 

2 

5  ;   2 

3 

31-40       " 

44 

21 

23 

47 

26 

21 

2 

2 

10     7 

J 

41-50       " 

70 

33 

37 

37 

21 

16 

3 

2 

I 

5  '   4 

I 

51-60       " 

37 

20  1    17 

33 

16 

17 

I 

I 

3  :  3 

61-70       " 

13         4         9 

II 

2 

9 

.     . 

Over  70      " 

I       .    .         I 

i 

I 

I 

I 

I 

(71) 

(73) 

CHAPTER  VIII. 

INFLUENCE  OF  GASTRIC  DISEASES  UPON    OTHER 
ORGANS  AND  ON  METABOLISM. 

Diseases  of  the  stomach  may,  as  is  well  known,  affect  general 
nutrition,  the  action  of  the  heart,  lungs,  and  the  nervous  system. 

In  all  digestive  diseases  with  apparent  malnutrition  the  physi- 
cian should  ascertain  the  amount  and  the  kind  of  food  ingested, 
the  state  of  the  stool,  and  sleep.  The  cause  of  insufficient  inges- 
tion of  food  is  anorexia  in  the  majority  of  cases;  in  others  the 
patients  have  a  good  appetite,  but  avoid  food  because  it  gives  them 
pain,  as  in  the  case  of  gastric  ulcer;  others,  again,  will  not  eat 
because  they  vomit  the  food  soon  after  ingestion.  Loss  of  weight 
is  of  more  serious  significance  in  chronic  than  in  acute  stomach 
diseases.  Instead  of  taking  in  30  to  40  calories  per  kilogram  of 
body  weight,  von  Noorden  found  in  chronic  types,  after  careful 
observation,  that  they  ingested  only  21  calories  of  their  own 
accord  (v.  Noorden,  "  Ueber  Stoffvvechsel  d.  Magenkranken,"  etc., 
Berliner  Klinik,  Heft  55).  In  cases  in  which  the  HCl  secretion 
was  so  diminished  that  only  a  fraction  of  the  proteids  could  be 
peptonized  in  the  stomach  and  the  largest  portion  passed  into  the 
intestines  unchanged,  von  Noorden  found  that  resorption  of  the 
main  food-substances  was  sufficient.  With  a  good  gastric  peris- 
talsis, preventing  delay  and  fermentation  in  the  stomach,  the  intes- 
tine is  capable  of  supplanting  the  deficient  gastric  digestion.  In 
animals,  total  exclusion  of  the  stomach  from  the  digestive  act 
need  not  injure  general  nutrition,  provided  the  food  is  supplied  in 
a  proper  form. 

It  is  very  probable  that  in  certain  forms  of  gastritis,  in  ectasias 
and  carcinoma,  poisonous  substances  are  formed  which  are  re- 
sorbed  and  injure  the  metabolism  of  the  tissues.  Friedenwald  has 
recently  found  this  to  be  the  case  in  atony  of  the  intestines  and 
stomach  {Hied.  News,  Dec.  23,  1893). 

Resorbable  and  combustible  gases  occur  in  gastrectasias  with 
stagnating  ingesta  and   have  been   described   by  many  observers 

358 


INFLUENCE    OF    GASTRIC    DISEASES    ON    THE    HEART.  359 

(see  Albu,  "  Die  Autointoxicationen  des  Intestinaltractus,"  p.  19). 
Putrefaction  of  albuminous  substances  may  occur  in  the  stomach, 
as  Boas  has  repeatedly  observed.  Some  cases  show  the  formation 
of  sulphuretted  hydrogen  even  with  co-existent  high  acidity. 
Naturally,  stagnation  must  be  present  to  make  albuminous  decom- 
position possible.  Miiller  has  described  a  series  of  carcinoma 
cases  in  which  more  nitrogen  was  excreted  than  ingested  in  the 
food  [Zeitsclir.  f.  klin.  Med.,  Bd.  xvi),  which  strengthens  the  concep- 
tion of  carcinomatous  auto-intoxication,  causing  an  increased  albu- 
minous breakdown  in  the  tissues. 

In  all  cases  of  subnormal  nutrition  all  etiological  factors  must 
be  sought  out  and  an  individualized,  highly  nutritious,  concen- 
trated, unirritating  diet  adapted  to  the  patient  after  improving  the 
appetite. 

Influence  of  Gastric  Diseases  on  the  Heart. —  It  is  natural  to 
expect  increased  rapidity  of  the  heart's  action  in  all  gastric  diseases 
associated  with  fever,  such  as  the  various  forms  of  acute  gastritis, 
in  perigastritis,  and  other  complications  (peritonitis).  But 
tachycardia  has  frequently  been  observed  by  us  associated  with 
hyperacidity,  gastrosuccorrhea,  and  pneumatosis.  In  one  case  of 
the  latter  disease  the  tachycardia  was  so  persistent  as  to  require 
special  treatment  by  local  ice  bag,  aconite,  and  bromid  of  stron- 
tium. In  all  of  these  cases  fever  was  absent,  and  we  have  no 
experimental  basis  to  explain  the  phenomenon. 

Bradycardia  is  seen  much  more  frequently,  and  the  fact  that  it 
is  aggravated  and  improves  or  disappears  as  the  gastric  trouble 
becomes  worse  or  better,  shows  that  it  is  not  an  accidental  accom- 
paniment, but  is  in  some  causal  relation  with  the  fundamental 
disease,  i.  e.,  dilatation  or  ulcer.  In  animals,  slowing  of  the  pulse 
can  be  effected  by  distention  or  rough  manipulation  of  the 
stomach.  Stimulation  of  sensory  nerves  causes  slowing  of  the 
heart  beat,  and  this  may  partly  be  offered  as  an  explanation  of 
bradycardia  in  dilatation  and  ulcer,  though  it  is  far  from  satis- 
factory. It  is  difficult  to  prove  that  irregular  heart's  action  or 
arrhythmia  is  dependent  upon  gastric  diseases  even  when  it  actually 
is  associated  with  the  latter.  Arrhythmia  is  so  frequent  that  it  may 
accidentally  be  present  in  an  individual  independently  of  any  gastric 
disease. 

Respiration. — It  is  undoubted  that  breathing  is  influenced  by 
gastric  troubles,  although  sufficient  attention  has  not  been  given 


360  INFLUENCE    OF    GASTRIC    DISEASES    ON    OTHER    ORGANS. 

to  this  matter.  We  have  noticed  in  a  number  of  cases  that  the 
respiratory  expansion  is  lessened  by  gastric  diseases  impeding  the 
excursions  of  the  diaphragm.  This  we  have  produced  experi- 
mentally in  healthy  individuals  by  inflating  our  stomach-shaped 
intragastric  rubber  bag  within  their  stomach  while  they  were  under 
narcosis. 

It  appears,  therefore,  that  undue  or  excessive  gastric  distention 
diminishes  the  amount  of  inspired  air,  independently  of  conscious- 
ness. In  gastric  fermentations  toxic  substances  are  produced, 
which,  when  injected  into  the  circulation,  caused  dyspneic  respira- 
tion of  a  paroxysmal  character  (Bouchard  and  Bouveret).  It  is 
probable,  therefore,  that  gastric  diseases  may  affect  respiration 
either  directly  or  mechanically,  through  interference  with  the 
descent  of  the  diaphragm  or  by  the  absorption  of  toxins  and 
action  on  the  respiratory  center.  With  the  intimate,  mutual  cor- 
relation of  the  physiology  of  the  circulatory  and  respiratory  func- 
tion, it  is  evident  that  a  pathological  disturbance  of  one  will 
inevitably  affect  the  other. 

The  Influence  of  Gastric  Diseases  on  the  Nervous  System. 
— Nervous  patients  affected  with  a  disease  of  the  stomach  fre- 
quently exhibit  neuroses  of  sensation,  hyperesthesia,  intercostal 
neuralgias,  and  hemicrania.  That  there  is  some  etiological  con- 
nection between  the  stomach  and  these  conditions  is  made  very 
probable  by  the  fact  that  very  frequently  they  only  occur  after  full 
meals  (dinner),  or,  if  they  existed  before,  they  are  aggravated  by 
copious  eating,  and  become  ameliorated  or  disappear  as  digestion 
is  completed.  The  pains  often  return  toward  night  and  on  going 
to  bed,  causing  insomnia.  Patients  that  are  experienced  in  the 
use  of  the  stomach-tube  are  able  to  arrest  these  pains  at  times  by 
lavage.  Occasionally  the  colon  is  the  cause  of  the  pain  irradia- 
tion ;  this  is  especially  to  be  looked  for  in  membranous  colitis  or 
compression  of  the  colon  from  tight  lacing,  or  in  the  various  forms 
of  enteroptosis. 

Gastric  vertigo  is  a  form  of  dizziness  or  partial  unconsciousness 
without  pain,  but  frequently  with  nausea  and  vomiting,  occurring 
in  gastric  sufferers.  Trousseau,  who  gave  a  classical  description 
of  this  affection,  argued  that  one  of  its  peculiarities  was  that  con- 
sciousness remained  clear  during  the  attack  (Trousseau,  "  Clin, 
del'  Hotel  Dieu,"  Paris,  tome  iii,  1868). 

We    have    observed    transient    loss   of  consciousness  which   at 


GASTRIC    VERTIGO.  36 1 

times  developed  from  typical  stomach  vertigo.  This  affection 
occurs  in  neuropathic  patients  with  hyperacidity,  particularly  when 
the  stomach  is  empty,  and  is  associated  more  often  with  this  gas- 
tric neurosis  than  others. 

It  is  a  more  frequent  complication  of  hyperchylia  than  is  gener- 
ally known,  since  many  patients  will  not  speak  of  their  transient 
attacks  unless  especially  questioned.  Emesis  often  checks  the 
attack,  and  Trousseau  mentions  that  a  cup  of  bouillon  or  a  cake 
soaked  in  wine  may  check  the  vertigo. 

Treatment  of  the  fundamental  gastric  disease  removes  the 
vertigo,  as  a  rule,  but  in  explanation  of  the  way  in  which  the  ver- 
tigo is  caused,  its  nervous  mechanism,  etc.,  we  have  nothing  but 
hypotheses. 

Symptoms. — The  symptoms  of  gastric  vertigo  are  nausea,  eruc- 
tation, pyrosis,  vomiting,  sensitiveness  in  the  epigastric  region,  pain 
in  the  stomach,  and  a  feeling  of  pressure,  fullness,  and  distention. 
In  the  majority  of  cases  constipation  exists,  and  the  abdomen  is 
frequently  distended  with  gases.  In  some  few  cases  a  dilatation  was 
found  to  be  present.  Vertigo  has  been  observed  to  occur  almost 
at  any  stage  of  digestion — before,  during,  and  after  meals.  Some- 
times the  attacks  of  giddiness  are  announced  by  a  sensation  of  great 
hunger  or  bulimia.  Leube  mentions  that  gastric  vertigo  may  occur 
in  some  persons  after  the  ingestion  of  certain  foods.  It  may  occur 
either  at  intervals  of  several  days  or  several  times  in  the  same  day. 
It  is  generally  a  chronic  and  permanent  trouble,  but  in  its  lighter 
forms  it  has  no  serious  influence  on  the  condition  of  the  patient. 
The  treatment  of  gastric  vertigo  necessitates  the  treatment  of  the 
underlying  condition  of  the  stomach. 

Leube  has  described  an  intestinal  vertigo  associated  with  intes- 
tinal diseases  of  various  kinds,  but  generally  not  of  a  serious  char- 
acter. The  most  frequent  causes  are  constipation  and  intestinal 
parasites,  mainly  lumbricoid  and  tapeworms.  These  attacks  of 
gastric  vertigo  are  as  yet  not  satisfactorily  explained.  Leube  has 
in  some  cases  been  able  to  produce  the  attack  by  pressure  on  the 
stomach  or  intestines  (Leube,  "  Ueber  den  Magenschwindel " ; 
Ziemssen's  "  Handb.  d.  spec.  Path.  u.  Ther.,"  vol.  11,  p.  66).  Mayer 
and  Pribram  claim  to  have  observed  excitation  of  the  vasomotor 
center  after  irritation  of  the  stomach,  particularly  of  the  serous  coat 
(Mayer  and  Pribram,  "  Ueber  reflect.  Bezieh.  d.  Magens  z.  d. 
Innervationscentren  f  d.  Kreislaufsorg.,"  Sitzungsber.  d.Wien.  Akad. 
24 


362      INFLUENCE    OF    GASTRIC    DISEASES    ON    THE    NERVOUS    SYSTEM. 

d.  Wiss.,  1872).  A  second  theory  in  explanation  of  stomach  vertigo 
presumes  that  it  is  caused  by  cerebral  anemia,  or  hyperemia, 
which  is  not  described  as  a  reflex  act,  but  as  a  direct  detrimental 
influence  on  the  circulation  of  the  brain.  This  hypothesis  exag- 
gerates the  degrees  of  circulatory  variation  that  can  possibly  occur 
in  such  light  forms  of  digestive  disturbance  in  which  vertigo  is 
observed.  A  third  theory  explains  gastric  vertigo  on  the  basis  of 
auto-intoxication.  It  is  presumed  that  products  of  abnormal  diges- 
tion, which  collect  when  the  motor  function  of  the  stomach  and 
intestines  is  disturbed,  are  absorbed  into  the  circulation,  and  act 
directly  upon  the  brain.  There  is  an  abundance  of  experimental 
evidence,  as  well  as  clinical  experience,  which  proves  that  such  an 
effect  of  toxic  chemical  substances  is  possible.  Such  toxic  irrita- 
tion may  be  indirect,  and  is  intermediated  through  the  vasomotor 
center.  Brieger  has  isolated  a  substance  from  dilated  stomachs, 
which  he  has  termed  peptotoxin,  which  has  an  extremely  poisonous 
effect  when  injected  into  the  circulation  of  animals.  In  case  of  the 
presence  of  intestinal  parasites,  the  toxic  metabolic  products  of  the 
helminthiasis  are  added  to  those  of  disturbed  digestive  function. 

Tetany. — The  term  signifies  characteristic  convulsive  attacks 
which  occur  in  the  course  of  gastric  diseases,  particularly  with  dila- 
tation associated  with  hypersecretion.  The  term  "tetany"  was  first 
used  in  1852  by  Corvisart.  The  spasms  are  prevailingly  tonic 
contractions,  alternating  with  less  severe  twitchings  in  the  flexor 
muscles  of  the  arms,  calves,  and  generally  also  of  the  abdominal 
muscles.  The  facial,  cervical,  and  maxillary  muscles  are  occasion- 
ally attacked  by  the  tetany,  the  eyes  may  be  turned  upward,  and 
even  emprosthotonos  of  short  duration  has  been  reported.  The 
convulsions  may  be  painful  and  consciousness  ma}'  be  clear  or 
completely  obscured.  In  one  case  of  Kussmaul's  the  power  of 
speech  was  lost ;  in  another  case  the  patient  spoke  disconnectedly 
and  his  pupils  did  not  react  to  light.  In  a  third  case  the  symp- 
toms referring  to  the  cerebrum  were  absent,  but  a  fourth  case  of 
Kussmaul's  was  of  an  epileptic  form  and  character.  Bouveret  and 
Devic  ("  Rech.  clin.  et  experim.  sur  la  tetanie  d'origine  gastrique," 
Revue  de  Medic,  1892,  12,  p.  48)  have  collected  23  cases  of  these 
tetanic  attacks,  and  Albu  ("  Autointoxicationen  des  Intestinaltrac- 
tus,"  Berlin,  1895)  states  that  not  more  than  36  cases  of  this 
complication  of  gastric  diseases  have  been  reported.  Kussmaul  gave 
the  first  classical  description  of  these  attacks  in  his  famous  publica- 


TETANY    OF    GASTRIC    ORIGIN.  363 

tion  on  the  treatment  of  gastric  dilatations  by  a  new  method  by 
means  of  the  stomach-pump  {Deiitsclies  Archiv  f.  klin.  Med.,  Bd.  vi). 

Clinically,  it  is  not  correct  to  designate  all  tonic  muscular  con- 
vulsions of  gastric  origin  as  tetany.  In  true  gastric  tetany  there  is 
an  increased  mechanical  excitability  of  the  muscles,  and  an  increased 
mechanical  and  electrical  irritability  of  the  motor  and  sensory 
nerves,  which  precede  the  attack  and  may  persist  long  after  it. 
Cases  have  been  reported  by  Fleiner  and  Kussmaul  which  strongly 
resembled  typical  tetanus.  Cases  are  reported  in  which  the  clinical 
picture  varied  between  tetany,  tetanus,  and  epileptiform  convul- 
sions. In  most  of  the  cases  Trousseau's  phenomenon,  /.  e.,  the 
production  of  spasms  by  pressure  on  the  nerve  trunks,  was  present. 
Among  27  cases  that  were  collected  by  Riegel,  16  proved  fatal. 
According  to  this,  tetany  is  a  very  grave  complication  of  gastric 
diseases.  The  gastric  diseases  with  which  tetany  is  associated  are 
extensive  dilatations,  due  mostly  to  stenosis  of  the  pylorus  or  duo- 
denum, by  ulcer  or  cicatrix.  In  several  cases  the  stenosis  was  due 
to  a  carcinoma  that  had  developed  from  a  cicatrix.  Bouveret  and 
Devic  attribute  great  importance  to  hypersecretion  for  the  produc- 
tion of  tetany.  This  complication  has,  however,  been  observed  in 
other  dilatations  in  which  there  was  no  hypersecretion.  Thus  far 
three  hypotheses  have  been  put  forward  attempting  to  explain  the 
origin  of  tetany  :  (i)  That  of  Kussmaul,  according  to  which  it  is 
caused  by  desiccation  of  the  organism  in  consequence  of  copious 
loss  of  water.  (2)  The  explanation  according  to  which  tetany  is 
caused  by  a  reflex  irritation  of  the  central  and  peripheral  nervous 
systems,  and  that  the  irritation  issued  from  the  central  branches 
of  the  gastro-intestinal  tract.  (3)  That  of  auto-intoxication,  which 
is  the  most  probable. 

Kussmaul's  theory  rested  upon  the  apparent  analogy  between 
tetany  and  the  cramps  in  the  legs,  occurring  with  Asiatic  cholera, 
which  are  believed  to  be  due  to  condensation  and  thickening 
of  the  blood,  resulting  from  loss  of  water.  We  know,  however, 
that  these  cramps  occur  also  in  cholera  sicca.  The  loss  of  water, 
Kussmaul  thought,  was  brought  about  by  the  exhaustive  vomiting 
which  usually  precedes  the  attack  of  tetany,  but  cases  have  been 
reported  in  which  tetany  occurred  without  a  preliminary  attack  of 
vomiting.  In  cholera  nostras  (the  acute  gastro-enteritis  of  children), 
where  the  loss  of  water  is  very  great,  tetany  occurs  very  rarely, 
but  it  is  a  frequent  accompaniment  of  chronic  digestive  diseases. 


364  TETANY    CAUSED    BY    AUTO-INTOXICATIOX. 

Blazicek  described  a  case  of  gastric  tetany  in  which  the  per- 
centage of  water  in  the  blood  was  not  reduced. 

The  second  theory,  that  of  the  reflex  origin,  has  been  proposed  by 
Germain  See.  The  arguments  of  Bouveret  and  Devic,  and  of 
Evvald  {Berlin,  klin.  Wocheiischr.,  1894,  No.  2),  emphasize  the  fact 
that  the  reflex  phenomena  are  based  upon  a  preliminary  chronic 
intoxication,  which  increases  the  irritability  of  the  muscles  and 
nerves.  Tetany,  according  to  these  authors,  is,  therefore,  not  a 
reflex  phenomenon,  any  more  than  are  the  convulsions  of  a  strych- 
ninized  frog,  w'hich  result  from  the  slightest  cutaneous  irritation. 

The  most  modern  authors  (Gerhardt,  Bouveret  and  Devic,  Albu, 
Ewald,  Heim,  Loeb,  Schlesinger,  and  Baginsky)  favor  an  explana- 
tion of  tetany  on  the  basis  of  gastro-intestinal  auto-intoxication. 
It  is  not  a  bacterial  intoxication  caused  by  metabolic  products 
of  pathogenic  bacteria  introduced  with  the  food  w'hich  these 
authors  have  reference  to,  but  to  poisons  formed  in  the  stagnating, 
fermenting  contents  of  the  dilated  stomach.  Kulneffhas  extracted 
toxic  products  from  the  gastric  contents  in  carcinoma  and  dilata- 
tion, which,  according  to  their  chemical  structure,  were  classed 
as  diamins.  These  toxins  were  extracted  by  Brieger's  method 
(extraction  with  alcohol  and  precipitation  with  mercuric  chlorid). 
Bouveret  and  Devic  extracted  substances  from  the  stomachs  of 
three  cases  of  tetany  with  hyperchlorhydria  that  produced  spasms 
when  injected  into  animals.  Ewald  and  Jacobson  have  isolated 
alkaloidal  bodies  from  the  urine  of  tetany  patients,  and  Albu  isolated 
the  double  platinic  and  gold  salt  of  an  alkaloidal  substance  from 
the  urine  of  a  woman  afflicted  with  tetany.  This  substance  was 
absent  from  the  urine  when  the  patient  was  free  from  the  attacks. 
Tetany  occurs,  in  the  majority  of  cases,  only  when  abnormal  fermen- 
tations and  putrefactions  occur  in  the  stagnated  contents  of  the 
stomach  and  intestines.  This  intoxication  theory  explains  the 
nephritis  which  Loeb  has  observed  in  connection  with  tetany.  The 
author  has  reported  three  cases  of  nephritis  which  undoubtedly 
owe  their  origin  to  auto-intoxication  (Hemmeter,  Maryland  Med. 
Jour.,  July  24  and  31,  and  Aug.  7,  1897). 

Asthma  Dyspepticum. — In  1876  Henoch  described  a  clinical 
phenomenon  in  children,  in  which  attacks  very  similar  to  asthma 
were  associated  with  digestive  disturbances  (Henoch,  Berlin,  klin. 
Wochenschr.,  1876,  No.  18),  and  in  1882  Silbermann  described  simi- 
lar cases,  also  occurring  in  children  {Berlin,  klin.  Woehensehr.,  1882, 


DYSPEPTIC    ASTHMA.  365 

No.  23).  The  attacks  of  asthma  dyspepticum  are  characterized  by 
a  very  abrupt,  acute  onset,  after  a  very  evident  error  in  diet  or 
after  constipation  or  febrile  gastritis.  There  is  a  pronounced  dysp- 
nea with  cyanosis,  very  small,  compressible,  and  hurried  pulse, 
cold  extremities,  collapse,  and,  generally,  no  symptoms  of  severe 
gastric  disturbance.  The  symptoms  disappear  as  suddenly  as  they 
begin,  after  an  emetic  has  taken  effect  or  spontaneous  vomiting  has 
occurred.  Striimpell  ("  Specielle  Pathologic  u.  Therapie  ")  doubts 
the  existence  of  asthma  dyspepticum,  and  Riegel  also  ("  Die 
Erkrankungen  des  Magens,"  Wien,  1896,  S.  192).  The  literature 
on  this  subject  is  very  limited,  and  many  of  the  cases  reported  do 
not  impress  us  as  strictly  belonging  to  the  clinical  picture  of  asthma 
dyspepticum.  O.  ^osQwhdich.  {De7itsche  medicin.  Wochensclir.,  1879, 
No.  42)  describes  a  number  of  cases,  which,  although  he  separates 
them  from  dyspeptic  asthma,  very  much  resemble  this  clinical 
picture.  The  patient  complained  of  oppression,  want  of  air,  diffi- 
culty in  breathing,  and  a  sensation  of  fear.  The  scarcity  of  reports 
on  this  complication  is  explained  by  the  fact  that  the  physician 
very  rarely  has  an  opportunity  for  observing  these  cases  during  the 
attack  ;  as  a  rule,  they  cease  spontaneously  within  a  few  hours,  and 
are  frequently  interrupted  by  the  patients  by  mechanical  manipula- 
tions to  facilitate  vomiting. 

It  is  well  known  that  conditions  of  more  or  less  anxious  oppres- 
sion in  breathing  are  observed  occasionally  in  normal  individuals, 
but  more  frequently  in  those  afflicted  with  gastro-intestinal  diseases. 
The  attacks  occur  in  connection  with  the  larger  meals,  the  patients 
having  a  feeling  as  if  they  could  not  breathe  properly.  The 
respiratory  oppression  and  distress  cease  spontaneously  during  the 
course  of  digestion,  or  are  relieved  by  eructation  of  gases.  If 
these  abnormal  sensations  are  augmented,  and  when  they  occur  at 
short  intervals  and  after  moderate  ingestion  of  food,  the  condition 
becomes  pathological.  A  fear  of  smothering,  with  cyanosis,  cool 
extremities,  greatly  hurried  pulse,  and  dyspnea,  occurring  in  the 
sequence  of  gastro-intestinal  disturbances,  represent  a  clinical 
picture  which  we  can  designate  as  asthma  dyspepticum.  Oppler 
{Ailg-.  nied.  Centralztg.,  1896,  No.  71)  and  Lauterbach  {Wien.  vied. 
Presse,  1894,  No.  48)  have  each  described  one  case  of  asthma 
dyspepticum  as  a  sequence  to  gastric  atony.  The  case  of  Oppler 
recovered  under  lavage,  diet,  massage,  electricity,  and  the  use  of 
strychnin  and  belladonna.  The  cardinal  symptom  of  the  phenom- 
enon is  the  paroxysmal  dyspnea.     It  occurs  most  frequently  among 


366  INFLUEN'CE    OF    GASTRIC    DISEASES    OX    OTHER    ORGANS. 

women,  and  especially  among  the  neurasthenic  and  hysterical. 
Potain  (Association  pour  I'Avancement  des  Sciences,  Montpellier, 
1879)  and  Barie  [Revue  de  Medecin,  1883,  tome  in,  p.  i)  have 
together  reported  32  cases  in  France,  a  number  of  which  gave 
indications  that  they  were  asthma  dyspepticum.  Boas  [Archiv  f. 
VerdainuigskrankJieiten,  Bd.  11,  p.  444)  gives  a  very  interesting 
report  of  11  cases, — ten  males  and  one  female. 

Instead  of  going  into  details  concerning  the  symptomatology, 
we  will  describe  a  case  which  has  been  observed  by  the  author 
repeatedly  during  attacks. 

The  lady  in  question  lived  in  the  immediate  neighborhood  of  the  writer. 
^Irs.  S.,  aged  twenty-six,  has  suffered  for  years  with  symptoms  of  atony  ; 
mother  living  and  healthy  ;  father  died  with  cancer  of  the  stomach  ;  she  has 
been  married  four  years,  but  has  no  children  ;  heart  and  lungs  normal.  The 
dyspeptic  symptoms  are  those  of  atony  and  nervous  dyspepsia.  There  are  no 
signs  of  enteroptosis  ;  right  kidney  is  firmly  attached  in  its  normal  position  ;  no 
history  of  uterine  trouble ;  constipation.  Results  of  analysis  of  test-meal :  Total 
acidity,  90  ;  free  HCl,  50  ;  combined  HCl,  22  ;  erythrodextrin  present  in  excess  ; 
lactic  acid  absent.  Examination  of  the  urine  for  toxic  products  gave  the  fol- 
lowing results  when  it  was  first  examined  ;  this  was  shortly  after  an  attack,  and 
was  also  followed  by  an  attack  on  the  next  day :  Preformed  sulphates,  3.970 
gm.  ;  combined  sulphates,  0.35  gm., — ratio,  11. i  ;  urea,  51.028  gm.  ;  indigo  blue, 
very  strong  reaction.  On  this  date  the  patient  was  very  melancholy,  and  suf- 
fered much  from  intestinal  flatulence.  The  writer  was  called  just  as  an  attack 
was  beginning,  and  found  the  patient  on  the  sofa,  with  the  servants  rubbing 
her  hands  and  feet,  which  had  a  bluish  tint  and  were  quite  cold  to  the  touch. 
She  was  gasping  for  breath  ;  the  pulse  was  148.  There  was  a  very  peculiar 
wheezing  sound  with  each  breath,  and  tenderness  to  pressure  in  the  epigastric 
region ;  accentuation  of  the  second  cardiac  sound.  A  stomach-tube  was 
passed,  and  about  500  gm.  of  highly  acid  liquid  drawn  off,  composed  mostly  of 
ice  cream  and  strawberries.  An  enema  was  given  containing  warm  claret  and 
camphor,  and  hot  bottles  were  placed  to  the  feet.  The  patient  broke  out  in  a 
perspiration  within  thirty  minutes  of  the  enema,  and  had  quite  recovered  two 
hours  after  the  attack.  This  same  patient  has  since  that  time,  which  was  a 
year  ago,  been  seen  in  two  other  attacks  very  similar  to  this  one,  both  of  them 
yielding  to  the  same  treatment. 

There  are  no  satisfactory  explanations  of  asthma  dyspepticum  up 
to  the  present  date.  Potain  {loc.  cit.)  believes  in  a  reflex  irritation 
from  the  gastro-intestinal  tract,  which  causes  contraction  of  the 
small  pulmonary  vessels.  In  the  resistance  to  the  pulmonary 
circulation  which  is  thus  brought  about,  the  respiratory  gaseous 
exchanges  are  interfered  with,  and  Potain,  as  well  as  Barie,  claim 
to  have  found  dilatation  of  the  right  ventricle,  with  accentuation 
of  the  second  pulmonary  sound  during  the  attack.     A.  P>ankel 


DYSPEPTIC    ASTHMA.  ^^J 

(article  on  "Asthma"  in  Eulenburg's  "  Real-Encyclopadie,"  3. 
Aufl.)  considers  asthma  dyspepticum  a  reflex  disturbance  of  car- 
diac asthma,  caused  especially  by  a  weakness  of  the  left  ventricle, 
which  then  secondarily  causes  a  passive  congestion  in  the  pul- 
monary circulation.  This  explanation  concedes  the  trouble  to 
be  essentially  cardiac  asthma.  There  is  a  very  intimate  connec- 
tion between  disturbed  digestion  and  cardiac  action,  which  we 
have  already  dwelt  upon,  and  the  conception  of  Frankel  is  not 
without  foundation  in  those  cases  in  which  the  heart's  action  is  not 
perfectly  sound.  Boas  has  reported  cases  in  which  the  attacks 
were  brought  on  by  a  disturbed  gastric  digestion,  with  bronchitis 
and  emphysema. 

Abnormal  gastro-intestinal  meteorism  may  force  up  the  dia- 
phragm me.chanically,  and  if  there  is  any  debility  about  the  pul- 
monary capillaries,  passive  congestion  can  not  fail  to  occur. 
With  the  evacuation  or  escape  of  the  gas  the  attack  will  cease 
entirely.  Senator  [Berlin,  klin.  Wochensclir.,  1883,  No.  22),  G.  Lewin, 
and  Albu  {loc.  cit.)  claim  that  dyspeptic  asthma  is  caused  b\-  the 
absorption  of  toxic  substances  from  the  digestive  tract.  The  theory 
of  auto-intoxication  has  been  criticized  by  Boas,  since  asthma  dys- 
pepticum is  not  met  with  in  any  gastro-intestinal  diseases  associated 
with  extensive  putrefaction  and  fermentation ;  whereas  in  those 
slight  forms  of  gastric  disease  in  which  this  asthma  really  does 
occur,  there  is  ver\'  little  formation  of  toxic  products. 

Prognosis  is  favorable.  Boas,  Lauterbach,  and  Oppler  have 
reported  cures.  One  of  our  cases  has  not  had  an  attack  for  eighteen 
months. 

Treatment  is  mainly  a  prophylactic  and  dietetic  one.  The  stom- 
ach should  be  sparingly  treated,  the  bowels  kept  open,  and  all  food 
causing  flatulence  must  be  scrupulously  avoided.  The  underlying 
neurasthenia  and  pulmonary  or  heart  affections  should  receive  thera- 
peutic attention.  In  atony  with  hyperacidity,  str}-chnin  sulphate, 
-^  of  a  grain,  with  ext.  belladonna,  ^  of  a  grain  three  times  daily, 
can  be  recommended.  During  the  attack  itself  speed}'  evacuation 
of  the  stomach  by  the  tube  and  of  the  bowel  by  warm-water 
irrigation  are  the  most  effective  means  of  treatment. 

The  patients  will  usually  not  object  to  the  tube  in  these  attacks, 
because  their  suffering  is  so  great  that  they  are  willing  to  undergo 
anything  to  be  relieved  ;  but  where  it  can  not  be  used  on  account  of 
heart  or  lung  trouble,  emetics  should  not  be  used  either,  because 


368       INFLUENCE   OF    NERVOUS    DISEASES    UPON    THE   STOMACH. 

they  are  more  depressing  upon  the  heart  than  the  use  of  the  tube. 
When  the  heart  is  sound  and  emesis  is  absolutely  indicated,  we 
recommend  the  following : 

R.     Pulvis  ipecac, 1.5,     or  grs.  xxiji 

Antimon.  et  potass,  tartrate, 0.05,  or  gr.  |.        M. 

SiG. — Make  two  powders,  to  be  taken  one-balf  hour  apart. 

Prompt  emesis  may  be  effected  by  the  use  of  apomorphin,  hypo- 
dermically,  in  doses  of  -jl^-  of  a  grain. 

The  Influence  of  Nervous  Diseases  Upon  the  Stomach. — 
This  subject  will  be  considered  in  connection  with  the  various 
nervous  disorders  of  digestion.  It  is  a  well-known  fact  that 
emotional  excitement  may  cause  an  alteration  in  the  gastric 
secretions,  and  that  intense  nervous  depression  may  produce  gas- 
tric distress,  fullness,  pressure,  eructation,  nausea,  constipation 
or  diarrhea,  meteorism,  and  tenesmus.  Mental  overexertion  may 
lead  to  nervous  dyspepsia.  Anatomical  alterations  in  the  central 
nervous  system  may  be  accompanied  by  motor,  secretory,  and 
resorptive  disturbances.  In  this  connection  we  refer  again  to  the 
gastric  disturbances  occurring  with  tabes,  and  to  the  fact  that  Koch 
and  Ewald  caused  gastric  hemorrhages  by  cutting  the  spinal  cord 
{Klinik  d.  Ver'dawuigskrankheiten^  loc.  cit.).  Brown-Sequard  and 
Schiff,  as  well  as  Ebstein  [Archiv  f.  exper.  Pathol.,  Bd.  11,  S.  183), 
produced  gastric  hemorrhage  after  experimental  injuries  to  the 
anterior  corpora  quadrigemina.  We  have  personally  observed  sub- 
mucous hemorrhages  and  small  areas  of  necrosis  in  the  stomach 
after  section  of  both  vagi  in  cats,  dogs,  rabbits,  and  guinea-pigs. 

Malaria. — It  is  a  very  well-known  fact,  and  generally  accepted 
by  the  physicians  of  the  Southern  and  Eastern  States,  that  malaria 
very  often  complicates  gastric  diseases,  and  may  even  be  an  under- 
lying cause.  It  is  very  probable  that  a  malarial  state  of  the  blood 
may  be  instrumental  in  causing  gastric  ulcer,  which  in  this  case 
has  been  asserted  by  London  to  be  due  to  pigment  emboli.  At 
our  clinic  it  is  a  standing  rule  to  examine  all  persistent  cases  of 
stomach  trouble  for  the  presence  of  the  malarial  parasite  in  the 
blood.  For  the  characteristics  of  this  organism,  and  the  methods 
of  examination,  we  refer  to  the  article  by  W.  H.  Welch  and  William 
S.  Thayer,  in  the  "  Loomis-Thompson  System  of  Medicine,"  and 
also  to  the  able  monographs  of  W.  S.  Thayer  on  this  subject.  In 
counties  of  the  eastern  shore  of  Virginia  malarial  gastralgia  is 
frequent.     Malaria    does    not,   as    a    rule,  affect  the    secretion    or 


INFLUENCE    OF    ANEMIA    AND    CHLOROSIS    ON    THE   STOMACH.       369 

motility,  except  in  the  various  forms  of  pernicious  malarial  fever.* 
In  gastric  troubles  showing  any  periodicity,  or  microscopic  or 
clinical  evidence  of  malaria,  quinin  should  be  promptly  adminis- 
tered, and  if  not  effective  within  twelve  hours  the  hydrobromate  of 
quinia  should  be  injected  hypodermically. 

Anemia  and  Chlorosis. — The  relation  between  pernicious 
anemia  and  atrophy  of  the  stomach  has  been  considered,  and 
the  claim  of  Austin  Flint  to  the  priority  of  this  clinical  associa- 
tion has  been  emphasized  in  the  chapter  on  Achylia  Gastrica. 
Anemia  and  chlorosis  are  influential  etiological  factors  in  the 
causation  of  gastric  diseases,  if  they  are  primary  conditions.  This 
relation  of  the  two  states  is  very  difficult  to  establish  and  probably 
very  rare.  Hayem  ("  Des  Alterations  du  chimisme  Stomacal  dans 
la  Chlorose,"  Bulletin  Med.,  1891,  No.  87)  asserts  that  the  altera- 
tions in  the  stomach  and  intestines  are  the  primary  cause.  Ewald 
and  Rosenheim  maintain  that  the  digestive  disturbances  may  be 
the  results  and  not  causes  of  the  anemia.  There  are,  undoubtedly, 
cases  in  which  the  anemia  is  the  cause,  and  others  in  which  it  is 
the  result.  In  some  instances  the  treatment  will  throw  light  on 
this  causative  relation.  If  the  secretory  and  motor  functions  of  the 
stomach  become  normal  with  the  cure  of  certain  anemia,  the  gastric 
disturbance  was  the  result  of  the  state  of  the  blood;  but  if  the 
secretory  and  motor  disturbances  are  marked,  and  perhaps  of  long 
standing,  and  examinations  show  only  a  slight  deviation  from  the 
normal  state  of  the  blood,  the  digestive  disturbance  is  the  primary 
one.  Often  it  is  possible,  when  patients  remain  under  observation 
for  a  long  time,  to  observe  the  progressive  anemia  developing  as  a 
sequence  to  gastro-intestinal  atrophy. 

The  effect  of  syphilis  on  gastric  digestion  has  been  considered 
in  a  separate  chapter. 

Pulmonary  Diseases. — The  most  prominent  among  these  is 
pulmonary  tuberculosis.  W.  Fenwick  found  gastritis  to  be  present 
in  nearly  all  the  cases  of  pulmonary  tuberculosis,  chronic  bron- 
chitis, emphysema,  and  acute  pneumonia.  He  asserts  that  in  dis- 
eases of  the  brain  no  gastric  involvement  was  observed  by  him 
[Virchozv's  Ai'chiv,  1889,  Bd.  cxviii,  S.  187);   he  found  gastritis  in 

*  A  very  reliable  and  accurate  Southern  colleague  informed  us  of  a  case  of  periodical 
hematemesis,  which  he  had  observed  near  Savannah,  occurring  every  third  day,  which 
was  cured  by  quinin.  A  form  of  the  algid  pernicious  malarial  fever  is  called  by  some 
Southern  doctors  "gastric  malarial  fever." 


370  INFLUENCE   OF    OTHER    DISEASES    ON    THE   STOMACH. 

II  cases  out  of  15  of  phthisis.  Marfan  ("  Troubles  et  Lesions  Gas- 
triques  dans  la  Phthisie  Poulmonaire,"  Paris,  1887)  found  but  five 
cases  in  61  of  tuberculosis  in  which  the  gastric  symptorns  preceded 
the  pulmonary.  It  is  very  difficult  to  decide,  when  a  dyspeptic  is 
at  the  same  time  affected  with  pulmonary  tuberculosis,  which  trouble 
is  primary.  As  a  rule,  diseases  limited  to  the  stomach  can  not  so 
weaken  the  general  state  of  health  as  to  predispose  to  pulmonary 
tuberculosis.  Rapid  exhaustion  from  localized  gastric  diseases 
occurs  only  in  carcinoma,  which  is  in  itself  rapidly  fatal  before  lung 
trouble  is  developed  to  any  great  extent;  but  when  the  gastric  dis- 
ease is  associated  with  intestinal  disturbances,  so  that  the  digestion 
is  very  much  interfered  with,  general  nutrition  may  be  so  impover- 
ished that  tuberculosis  can  be  more  readily  acquired.  Hutchinson 
("  The  Morbid  State  of  the  Stomach  and  Duodenum,"  London, 
1878)  publishes  an  analysis  of  a  large  number  of  cases,  and  states 
that  the  digestive  disturbances  precede  the  tubercular  infection  in 
about  one-third  of  the  cases.  It  is  in  these  cases  of  suspected 
pulmonary  disease,  associated  with  digestive  troubles,  that  the 
ability  of  a  good  auscultator  will  tell.  Gastro-enterologists  should 
not  fail  to  perfect  themselves  in  the  technic  of  auscultation  and 
percussion.  Whenever  sputum  can  be  obtained  it  should  be  exam- 
ined for  tubercle  bacilli.  The  state  of  the  gastric  secretion  and  the 
motor  function  in  tuberculosis  have  been  studied  by  Edinger  {loc. 
cit),  Rosenthal  {loc.  cit?j,  Shetty  {loc.  cit.),  O.  Brieger  {loc.  cit.). 
Immermann  {loc.  cit}),  Hildebrandt  {loc.  cit.),  and  Einhorn  {loc.  cit.). 
The  state  of  the  secretory  and  motor  functions  in  pulmonary  phthisis 
varies,  in  our  experience,  with  the  stage  of  the  pulmonary  disease. 
In  the  incipient  stages  of  phthisis,  secretion  and  motility  may  be 
normal  for  a  long  time ;  they  will  become  more  and  more  deranged 
as  the  pulmonary  trouble  progresses,  so  that  in  the  final  stages  of 
pulmonary  caseation,  breakdown,  and  formation  of  cavities,  all  gas- 
tric function  may  be  extinguished.  Brieger  {loc.  cit.)  states,  that  in 
the  initial  stages  the  cases  of  normal  and  disturbed  secretion  are 
about  equally  divided.  In  moderately  severe  cases  secretion  was 
normal  only  in  one-third,  or  33  per  cent.;  in  the  remainder,  secre- 
tion was  variable,  but  generally  depressed.  In  6.6  per  cent,  there 
was  no  secretion  whatever.  In  advanced  cases  of  phthisis  secretion 
was  normal  only  in  16  per  cent,  of  the  cases.  It  was  more  or  less 
defective  in  the  rest  of  the  cases,  and  in  9.6  per  cent,  there  was 
complete  arrest  of  secretion.    Immermann  {loc.  cit.)  found  the  gastric 


EFFECT    OF    PULMONARY    DISEASES    ON    THE    STOMACH,  37 1 

peristalsis  normal  in  53  out  of  54  tests,  whereas  Klemperer  {loc.  cit?) 
claims  to  have  found  marked  inhibition  of  the  peristalsis  by  his 
method.  The  amount  of  gastric  secretion  and  the  state  of  the  peri- 
stalsis are  not  satisfactory  exponents  of  the  digestive  powers  of 
phthisical  patients.  The  only  correct  way  to  find  out  whether  such 
patients  have  digestive  power  sufficient  to  maintain  the  nitrogen 
equilibrium  is  by  quantitative  experiments  on  vietabolisni.  By  giving 
weighed  amounts  of  certain  foods,  and  determining  the  quantity 
that  is  digested  and  the  quantity  that  is  excreted  undigested,  to- 
gether with  careful  determination  of  the  amount  of  nitrogen  in  the 
urine,  we  have  been  able  to  discover  that  tuberculous  patients,  with 
absolute  achylia  gastrica,  may,  with  care  as  to  diet,  still  be  able  to 
retain  their  nitrogen  equilibrium,  provided  the  gastric  peristalsis 
was  preserved.  In  future,  the  exact  state  of  the  pulmonary  disease, 
its  duration  and  extent,  together  with  a  statement  of  the  condition 
of  all  the  remaining  organs,  would  be  desirable,  if  the  correlation 
existing  between  gastric  and  pulmonary  troubles  is  to  be  put  upon 
a  basis  of  approximate  exactness.  Although  the  treatment  of  the 
tuberculosis  is  the  main  object,  it  will  be  impossible  to  maintain 
nitrogen  equilibrium  with  a  defective  digestive  apparatus ;  it  is, 
therefore,  essential  that  the  functions  of  the  stomach  should  be 
improved  as  far  as  possible.  In  this  way  a  system  of  forced  ali- 
mentation, such  as  has  been  very  successfully  employed  by  Debove 
{loc.  cit),  Dettweiler,  Liebermeister,  Leyden,  Riihle,  and  Peiper, 
may  become  possible.  In  each  individual  case  the  diet  and  the 
medicine  should  be  ordered  according  to  the  state  of  the  gastric 
functions  found  from  test-meals.  We  have  had  three  patients 
affected  with  pulmonary  tuberculosis  at  the  Maryland  General 
Hospital  during  the  winter  of  1896  and  1897,  who  gained  con- 
siderably in  weight  by  treatment  of  the  existing  gastritis.  One 
patient  with  pulmonary  tuberculosis  and  a  tubercular  rectal  fistula 
gained  14  pounds  in  two  months  under  daily  lavage  and  adminis- 
tration of  HCl  and  strychnin,  together  with  nutritious  diet.  The 
tuberculous  fistula  was  treated  by  Dr.  Samuel  T.  Earle,  and  healed 
up  completely  before  the  patient  left  the  hospital. 

Diseases  of  the  Heart. — We  have  already  spoken  of  the  effect 
of  gastric  disturbances  in  producing  tachycardia,  bradycardia,  and 
arrhythmia.  The  diseases  of  the  stomach  which  are  caused  by 
valvular  affections  of  the  heart,  are  brought  about  by  the  venous 
stasis  and  passive  congestion.     Under  the  head  of  chronic  gastritis 


372  INFLUENCE    OF    OTHER    DISEASES    ON    THE    STOMACH. 

we  have  spoken  of  the  efficacy  of  digitalis  when  valvular  disease  is  in 
clear  etiological  association  with  the  gastric  affection.  Concerning 
the  state  of  the  secretion  in  heart  diseases,  there  is  no  agreement  in 
the  observations  thus  far  reported.  In  20  patients  with  heart  disease, 
Adler  and  Stern  {Berl.  klin.  Wochaischr.,  1889,  No.  49)  found  free 
HCl  always  present  in  16,  variable  in  two,  and  always  absent  in 
two  cases.  Hiifler  states  that  in  ten  cases  of  mostly  valvular 
lesions,  suppression  of  the  secretion  of  HCl  and  absence  of  albumin 
digestion  was  found  nine  times,  and  hyperacidity  in  a  single  case. 
Most  of  his  patients  are  stated  to  ha\-e  been  in  the  stage  of  perfect 
compensation.  These  observations  of  Hiifler  are  not  intelligible 
in  the  light  of  the  pathological  physiology  of  cardiac  diseases.  For 
perfect  compensation  means  that  the  arterial  and  venous  pressure 
in  all  the  organs  is  normal;  under  this  state  we  can  not  conceive  of 
any  passive  congestion  in  the  stomach.  In  our  experience,  gastric 
secretion  was  normal  in  eight  cases  of  mitral  regurgitation,  two 
cases  of  aortic  regurgitation,  and  two  cases  of  mitral  insufficiency. 
As  soon  as  compensation  becomes  defective,  the  gastric  symptoms 
make  their  appearance,  and  secretion  is  found  altered. 

Diseases  of  the  Liver. — The  close  anatomical,  physiological, 
and  pathological  relationship  between  the  liver  and  the  stomach 
explains  the  sympathetic  manner  in  which  diseases  of  one  organ 
frequently  reflect  upon  the  other ;  excepting  in  the  diseases  of  the 
biliary  passages  and  gall-bladder,  it  is  impossible  to  say  which 
organ  is  primarily  affected.  During  the  passage  of  gall-stones 
gastric  secretion  is  suppressed ;  this  suppression  is  due  to  a  reflex 
influence  caused  by  the  intense  pain.  We  have  tested  the  vomited 
matter  which  was  brought  up  during  attacks  of  biliary  colic.  In 
three  cases  it  was  neutral  or  alkaline ;  in  one  case  it  showed  pres- 
ence of  combined  HCl — no  free  HCl.  The  alkalinity  of  this  vomit 
was  not  due  to  the  presence  of  bile,  or  pancreatic  juice,  because 
they  were  found  to  be  absent.  Cases  of  cirrhosis  of  the  liver,  and 
even  of  cancer  of  the  liver,  may  run  a  latent  course  for  a  longtime, 
the  symptoms  being  those  of  chronic  gastritis. 

Gout  and  Rheumatism. — Burney  Yeo  claims  that  dyspepsia  is 
a  frequent  and  prominent  manifestation  of  gout  {Brit.  Med.  Jour., 
Jan.  7  and  14,  1888).  This  specific  gouty  disorder  of  the  stomach 
is  claimed  to  exist  in  states  of  uric  acid  diathesis  by  a  number  of 
contributors  to  British  medical  journals,  but  Sir  William  Roberts, 
Sir  Dyce  Duckworth,  and  Haig  mention  nothing  about  it.     Ewald 


EFFECTS    OF    DIABETES    AND    RENAL    DISEASES.  373 

states  that  he  has  not  met  with  a  single  case  of  true  gout  with 
coincident  gastric  disturbances,  but  that  he  has  seen  numerous  such 
examples  in  chronic  articular  rheumatism,  in  which  the  dyspepsia 
was  so  marked  that  the  pains  in  the  joints  were  comparatively 
insignificant.  Anomalies  of  secretion  in  gout  have  been  repeatedly 
observed  by  us.   The  most  frequent  secretory  trouble  ishyperacidity. 

Diabetes  Mellitus. — Although  there  is  no  constancy  in  the 
character  of  the  secondary  gastric  symptoms  accompanying 
diabetes,  there  are  few  cases  of  this  disease  in  which  the  stomach 
is  not  involved.  Diabetes  affects  the  stomach  in  two  ways  prin- 
cipally, either  by  arresting  its  functions  through  auto-intoxication 
or  by  production  of  gastritis.  The  presence  of  great  thirst, 
polyuria,  polyphagia,  ocular  disturbances,  pruritus,  emaciation, 
usually  means  co-existent  gastric  involvement.  Rosenstein  and 
Gans  have  examined  the  gastric  functions  in  diabetes  (Rosenstein, 
Berl.  klin.  Wochenschr.,  1890,  No.  13).  Their  results  show  that 
the  disturbances,  although  present,  show  no  constancy  in  type. 
The  polyphagia  and  polydipsia  of  diabetes  have  been  known  to 
cause  gastrectasia. 

Diseases  of  the  Kidney. — The  stomach  is  always  more  or  less 
affected  in  renal  diseases,  and  the  symptoms  of  disturbed  gastric 
digestion  very  often  appear  long  before  albumin  is  present  in  the 
urine.  In  the  Maryland  Medical  Jotirnal,  July  24  and  31,  and 
Aug.  7,  1897,  we  have  reported  three  cases  of  nephritis  which 
were  undoubtedly  due  to  chronic  auto-intoxication  from  the 
gastro-intestinal  tract.  In  this  connection  we  wish  to  emphasize 
the  gastric  diseases  which  are  caused  by  pre-existing  affections 
of  the  kidneys.  Naturally,  it  is  unavoidable  that  a  certain  amount 
of  auto-intoxication  will  accompany  the  association  of  renal  with 
gastric  disease,  no  matter  which  is  the  primary  affection.  Albu 
{loc.  cit?)  and  Biernacki  {Berl.  klin.  Wochenschr.,  1891,  No.  25  and 
No.  26)  emphasize  the  influence  of  retained  metabolic  products 
in  producing  gastric  disturbances.  These  retained  products  of 
metabolism  injure  the  stomach  in  two  ways:  (i)  By  acting  as 
toxins  through  the  vascular  channels  directly  upon  the  paren- 
chyma of  the  gastric  walls,  and  (2)  by  irritation  of  the  surface 
of  the  stomach,  since  they  are  very  frequently  excreted  in  this 
manner.  Fenwick  [loc.  cit?)  states  that  the  gastric  mucosa  is 
capable  of  secreting  urea  like  the  intestinal  mucosa,  and  that  the 
excretion  of  this  product  causes   an   acute  catarrh    of  the  gastric 


374  INFLUENCE    OF    OTHER    DISEASES    ON   THE    STOMACH. 

glands.  A  variety  of  gastric  diseases  has  been  found  to  exist  in 
connection  with  chronic  Bright's  disease.  We  have  seen  that  acute 
and  chronic  gastritis,  fatty  degeneration  of  the  glandular  epithehum, 
and,  according  to  Ewald,  amyloid  degeneration  may  occur.  Edema 
of  the  gastric  walls  is  a  very  rare  complication.  The  effects 
of  floating  kidney  in  producing  stenosis  of  the  duodenum  have 
been  considered  in  the  chapter  on  Enteroptosis.  Allan  A.  Jones 
("  Gastric  Conditions  in  Renal  Disease,"  Nezv  York  Med.  Jotir.,]2in. 
19,  1895)  has  frequently  found  suppression  of  gastric  secretion  in 
patients  with  kidney  diseases.  Einhorn  reports  a  case  of  achylia 
gastrica  due  to  renal  calculus,  which  had  existed  for  a  long  time. 
After  removal  of  the  stone  by  operation,  the  gastric  symptoms  at 
once  disappeared.  According  to  Biernacki,  the  secretory  function 
is  arrested  in  renal  affections. 

Skin  Diseases. — There  can  be  no  doubt  that  digestive  troubles 
have  an  influence  in  the  production  of  eczema,  urticaria,  erythema, 
the  various  forms  of  acne,  and  pemphigus  ;  but  there  is  no  evidence, 
vice  versa,  that  skin  troubles  have  any  effect  upon  the  gastric 
function,  excepting  extensive  cutaneous  burns.  When  the  skin 
has  been  destroyed  over  large  areas,  duodenal  and  sometimes 
gastric  ulcer  were  observed  to  develop.  The  homeopaths  assume  a 
great  many  digestive  troubles  to  be  caused  by  so-called  "  systemic  " 
itch,  and  Pedioux  {L' Union  Med.,  1866,  p.  235)  considered  dys- 
pepsia an  expression  of  a  herpetic  state  of  the  system.  These 
inferences  are  too  absurd  to  be  considered  seriously. 

LITERATURE 

ON   THE   CORRELATION   OF   DISEASES   OF    THE    STOMACH   TO   THOSE   OF    OTHER 

ORGANS. 

1.  W.  Fenwick,  "  Ueber  den  Zusammenhang  einiger  krankhafter  Zustande 
des  Magens  mit  anderen  Organerkrankungen,"  Vitxhoivs  Archiv,  1889,  Bd. 
cxviii,  S.  187. 

2.  Samuel  Fenwick,  "Atrophy  of  the  Stomach,"  London,  1880,  p.  49. 

3.  Henry  and  Osier,  "Atrophy  of  the  Stomach,  with  Clinical  Features  of 
Progressive  Pernicious  Anemia,"  Aitierican  Jour,  of  Med.  Sciences,  April, 
1886. 

4.  Handfield  Jones,  "  Diseases  of  the  Stomach." 

5.  Hutchinson,  "The  Morbid  States  of  the  Stomach  and  Duodenum," 
London,  1878. 

6.  B.  Marfan,  "  Troubles  et  lesions  gastriques  dans  la  phthisie  poulmonaire," 
Paris,  1887. 

7.  C.  Rosenthal,  "Ueber  das  Labferment,"  Berliner  klin.  Wochenschr., 
1888,  No.  45. 


LITERATURE.  375 

8.  Klemperer,  "  Ueber  die  Dyspepsia  der  Phthisiker,"  Ibid.,  1889,  No.  11. 

9.  Schetty,  loc.  cit.,  Deiitsches  Archiv  f.  klin.  Med.,  Bd.  XLlv,  S.  219. 

10.  O.  Brieger,  "  Ueber  die  Functionen  des  Magens  bei  Phthisis  pulmonum," 
Deutsche  med.  Wochenschr.,  1888,  No.  14. 

11.  H.  Hildebrand,  Ibid.,  1889,  No.  15. 

12.  Immermann,  "  Verhandlungen  des  Congresses  fiir  innere  }*Iedicin," 
Wiesbaden,  1889. 

13.  Grusdevv  (Wratsch,  1889,  Nos.  15,  16,  Coiiralblati  Ji'ir  klin.  Med.,  1890, 
S.  92-Tr.). 

14.  Iwan  Bernstein,  "  Die  Dyspepsie  der  Phthisiker,"  Inaug. -Dissert., 
Dorpat,  1889. 

15.  Hayem,  "Des  alterations  du  chimisme  stomacal  dans  la  chlorose,"  Bul- 
letin Medic,  1 89 1,  No.  87. 

16.  Buzelygan  und  Gluczinsky,  "  Ueber  das  Verhalten  des  ^lagensaftes  bei 
den  verschiedenen  Formen  der  Anamie  und  besonders  der  Chlorose,"  Inter- 
nal, klin.  Rundschau,  1891,  No.  34. 

17.  Pick,  "  Therapie  der  Chlorose,"  Wienernied.  Wochenschr.,  1891,  No.  50. 

18.  Hiifler,  "Ueber  die  Functionen  des  Magens  bei  Herzfehlern,"  Munch, 
med.  Wochenschr.,  1889,  No.  33. 

19.  Adler  und  Stern,  "Ueber  die  Magenverdauung  bei  Herzfehlern,"  Berl. 
klin.  Wochenschr.,  1889,  No.  49. 

20.  Fenwick,  loc.  cit. 

21.  Biernacki,  "  Ueber  das  \"erhalten  des  r^Iagens  bei  Nierenentziindung," 
Berl.  klin.  Wochenschr.,  1891,  Nos.  25,  26. 

22.  Ewald  (Neunter  Congress  fiir  innere  Medicin  zu  Wien,)  1S90. 

23.  CoUeville,  Progr.  med.,''  1883,  No.  20. 

24.  G.  Werner,  "  Gastrische  Krisen  als  Initialsymptom  einer  Tabes  dorsalis," 
Inaug.-Dissert.,  Berlin,  1889. 

25.  Rosenstein,  "Ueber  das  Verhalten  des  Magensaftes  und  ^lagens  bei 
Diabetes  mellitus  "   (Neunter  Congress  fiir  innere  ^ledicin,)  Wien,  1890. 

26.  Burney  Yeo,  "  On  the  Treatment  of  the  Gouty  Constitution,"  British 
Med.  Jourjial,  January  7  and  14,  1888. 

27.  Pidoux,  "  Rapport  de  I'herpetisme  et  des  dyspepsies,"  U?iion  vied.,  1886, 
No.  I. 

28.  Leube,  "  Beitrage  zur  Diagnostik  der  ^lagenkrankheiten,"  Deutsches 
Archiv  fiir  klin.  Med.,  Bd.  xxxiii. 

29.  Glax,  "Ueber  die  Neurosen  des  Magens,"  Wien,  1887,  S.  206. 

30.  Max  Einhorn,  N.  Y.  Med.  Record,  ]\Iay  4,  18S9;  also  Berlin,  klijt. 
Wochenschr.,  1889,  No.  48. 

31.  Allen  A.  Jones,  N.  V.  Med.  Jour.,  January  19,  1895. 

32.  Edinger,  Deutsches  Archiv  f.  klin.  Med.,  1891. 

33.  Edgar  Gans  (Neunter  Congress  fiir  innere  Medicin,)  1890,  Wiesbaden. 

34.  Illoway,  "  Cardiac  Disturb,  from  Gastric  Irritat.,"  N.  Y.  Med.  Jour., 
April,  1897. 

35.  Huchard,  "Maladies  du  Coeur." 

36.  Destureaux,  "  De  la  Dilatation  du  Coeur  Droit  de  I'Origine  Gastrique," 
These  de  Paris,  1879. 

37.  G.  See,  "  Du  Diagnostic,  etc.,  des  Malad.  du  Cosur." 

38.  Potain,  "  Congres  de  1' Association  Franc^aise,"  Paris,  1878. 


CHAPTER    IX. 
THE    BLOOD    AND    URINE    IN    STOMACH    DISEASES.* 

In  general  we  may  say  that,  while  we  are  unable  to  make,  in 
any  given  case,  the  diagnosis  of  stomach  disease  from  an  examina- 
tion of  the  blood  alone,  it  will,  in  many  instances,  render  great 
assistance  in  connection  with  other  symptoms. 

The  presence  of  an  oligocythemia  is  found,  in  cases  of  long- 
continued  stomach  disturbances,  serious  enough  in  character  to 
interfere  with  the  nutrition  of  the  body.  For  example,  in  chronic 
gastritis  there  is  always  a  moderate  degree  of  oligocythemia,  the 
decrease  in  the  number  of  red  corpuscles  running  nearly  parallel 
with  the  disturbance  of  nutrition. 

In  the  severe  forms  of  atrophic  gastritis  the  decrease  is  some- 
times enormous;  so  much  so,  that  many  of  these  cases  are  consid- 
ered as  cases  of  primary  pernicious  anemia,  the  true  cause  not 
being  discovered  until  the  postmortem  examination  is  made. 

In  cancer  of  the  stomach  the  oligocythemia  is  usually  marked, 
in  cases  of  well-developed  cachexia  the  number  of  red  corpuscles 
often  being  found  to  be  between  one  and  two  million,  in  some 
instances  falling  below  one  million. 

In  ulcer  of  the  stomach  quite  variable  conditions  may  be  found. 
In  cases  of  chronic  ulcer  of  the  stomach  with  slight  hemorrhages, 
the  blood  changes  may  be  those  of  a  simple  secondary  anemia,  or 
the  blood  may  approach  the  normal  in  its  proportions.  In  acute 
or  subacute  ulcer  of  the  stomach  the  blood  may  show  a  normal 
number  of  corpuscles,  unless  there  has  been  a  recent  hemorrhage 
of  considerable  severity.  In  case  of  hemorrhage,  the  decrease  in 
the  number  of  red  corpuscles  is  in  proportion  to  the  amount  of 
blood  lost. 

In  simple  or  benign  dilatation  of  the  stomach  the  anemia  is  pro- 
portional to  the  disturbance  of  nutrition  which  it  produces,  other 
things  being  equal. 

*  The  articles  on  "The  Condition  of  the  Blood  and  Urine  in  Stomach  Diseases" 
and  on  "  The  Stomach  Gases  "  were  written  bv  Dr.  E.  L.  Whitney. 

3/6' 


LEUKOCYTOSIS    IN    GASTRIC    DISEASES.  377 

Leukocytosis. — Considerable  may  be  learned  from  a  study  of 
the  occurrence  and  degree  of  leukocytosis  in  stomach  diseases. 

Under  normal  conditions  a  moderate  degree  of  leukocytosis 
(10,000  to  15,000)  develops  after  meals,  depending  upon  the  absorp- 
tion of  proteid  materials  from  the  gastro-intestinal  tract.  This  does 
not  take  place  in  the  majority  of  cases  of  cancer  of  the  stomach, 
but  does  occur  in  ulcer  of  the  stomach — a  fact  of  considerable 
diagnostic  importance. 

There  is  usualh'  present  in  cancer  of  the  stomach,  as  in  malig- 
nant disease  in  other  situations,  a  constant  increase  in  the  number 
of  white  corpuscles,  varying  from  10,000  to  50,000,  the  normal 
number  being  taken  as  about  7000  leukocytes. 

In  the  acute  inflammatory  diseases  of  the  stomach,  such  as  any 
of  the  forms  of  acute  gastritis,  there  is  present  leukocytosis  of  varj^- 
ing  intensity.  This  is  an  important  fact  to  remember  in  making  a 
diagnosis  between  acute  gastritis  and  typhoid  fever  in  its  early 
stages, — acute  gastritis  being  accompanied  by  a  moderate  leukocy- 
tosis, typhoid  fever  showing  a  normal  or  decreased  number  of 
leukocytes. 

After  severe  hemorrhage  from  a  gastric  ulcer,  gastric  cancer,  or 
from  varices  in  the  esophagus  or  stomach,  as  from  any  loss  of  blood, 
the  so-called  "posthemorrhagic  leukocytosis"  occurs — a  fact 
which  should  be  taken  into  account  in  forming  any  conclusions 
from  leukocytosis  in  the  course  of  gastric  diseases.  This  leukocy- 
tosis, as  a  rule,  disappears  in  about  three  or  four  days,  and  can  thus 
be  excluded  by  frequently  repeating  the  examination. 

Red  Corpuscles. — In  cancer  of  the  stomach  in  its  later  stages, 
the  red  corpuscles  frequently  show  the  changes  in  form  known 
as  poikilocytosis,  in  an  exquisite  manner.  In  cases  of  severe 
anemia  of  any  kind,  poikilocytosis  may  occur,  but  in  pernicious 
anemia  and  cancer  this  change  is  most  pronounced. 

Hemoglobin. — In  the  various  anemic  states  depending  upon 
diseases  of  the  stomach,  the  hemoglobin  is  decreased. 

In  ulcer  of  the  stomach  it  is  a  common  observation  to  find  a 
normal  or  only  slightly  decreased  number  of  red  corpuscles  with  a 
considerable  decrease  in  the  amount  of  hemoglobin,  the  so-called 
"  chlorotic  blood."  After  hemorrhages,  especially  when  severe, 
the  number  of  red  corpuscles  may  in  a  short  time  decrease  consid- 
erably. 

In  cancer  of  the  stomach  in  its  early  stages  the  blood  may  pre- 
25 


3/8  THE    BLOOD    AND    URINE    IN    STOMACH    DISEASES. 

sent  a  similar  picture  ;  but  in  the  later  stages  the  number  of  cor- 
puscles is  decreased  extremely,  the  hemoglobin  not  being  dimin- 
ished proportionally. 

In  other  diseases  of  the  stomach  the  alterations  are  usually  those 
of  secondary  anemia,  the  red  corpuscles  and  hemoglobin  being 
reduced  in  a  corresponding  ratio. 

Stained  specimens  of  blood  from  patients  suffering  with  the 
cancerous  cachexia  in  a  severe  form  will  usually  show  the  presence 
of  a  considerable  number  of  normal-sized  nucleated  red  corpuscles, 
as  well  as  megaloblasts,  the  latter  being  much  in  the  minority,  a 
point  which  may  be  of  importance  in  the  diagnosis  of  severe  can- 
cerous cachexia  from  primary  pernicious  anemia. 

After  severe  hemorrhages  from  gastric  ulcer,  fairly  numerous 
normoblasts  may  be  found,  in  addition  to  a  decrease  in  the  number 
of  red  corpuscles,  and  in  the  amount  of  hemoglobin.  These 
changes  may  be  of  importance  in  the  diagnosis  of  true  gastric 
hemorrhage  from  the  attempts  at  deception  made  by  malingerers 
and  hysterical  patients. 

In  chronic  atrophic  gastritis  the  blood  may  show  the  exact 
picture  of  a  primary  pernicious  anemia,  viz.,  marked  oligocy- 
themia, increase  in  color  index,  decrease  in  specific  gravity, 
presence  of  nucleated  red  corpuscles,  normoblasts,  microblasts,  and 
megaloblasts,  with  a  decrease  in  the  number  of  white  corpuscles. 
In  by  far  the  larger  number  of  cases,  however,  the  blood  changes 
are  simply  those  of  a  severe  secondary  anemia. 

Alkalinity  of  the  Blood, — The  researches  of  Loewy  concern- 
ing the  alkalinity  of  the  blood  in  health  and  disease,  by  the 
method  which  he  has  devised,  have  shown  the  sources  of  error  in 
the  methods  formerly  in  use,  and  rendered  a  revision  of  our 
opinions  necessary.  The  method  is  one  which  will  probably 
supersede  all  others  for  the  clinical  laboratory,  on  account  of 
simplicity  of  execution  and  accuracy.  At  present  there  are  not 
enough  observations  recorded  to  permit  us  to  speak  of  its  appli- 
cation in  diagnosis.  In  the  observations  made  with  reference  to 
digestion,  it  has  been  shown  that  a  rich  secretion  of  HCl  by  the 
stomach  increases  the  alkalinity  of  the  blood,  and  vice  versa. 
Whether  this  fact  can  be  of  utility  in  the  study  of  gastric  diseases 
must  I'emain  at  present  undecided. 

In  addition  to  the  examination  of  the  blood  for  the  preceding 
constituents,  it  may  be  of  importance  in   cases   of  continued   fever 


STATE    OF    THE    BLOOD    IN    GASTRIC    DISEASES.  379 

with  marked  gastric  symptoms,  in  which  the  diagnosis  lies  between 
some  severe  inflammatory  disease  of  the  stomach  and  typhoid  fever, 
to  make  a  trial  of  the  Widal  test  for  typhoid. 

This  test  is  of  no  value  in  the  early  days  of  the  disease,  the 
reaction  seldom  appearing  before  the  seventh  day,  and  rarely  only 
on  the  fifth  or  sixth  day. 

The  results  of  our  knowledge  of  the  blood  changes  in  the  vari- 
ous stomach  diseases  may  be  summed  up  as  follows  : 

Acute  Gastritis. — Usually  a  slight  degree  of  leukocytosis,  in- 
creasing with  the  intensity  of  the  inflammation. 

Clironic  Gastritis. — A  decrease  in  the  number  of  red  corpuscles 
and  hemoglobin,  the  leukocytes  showing  normal  numbers,  as  a 
rule. 

Chronic  Atrophic  Gastritis. — The  blood  may  show  the  same 
changes  as  in  the  simple  chronic  gastritis,  or  may  show  the  blood 
changes  of  pernicious  anemia  (poikilocytosis),  marked  decrease  of 
red  corpuscles,  a  marked  decrease  in  hemoglobin,  the  decrease 
being  less  in  proportion  than  that  of  the  red  corpuscles,  a 
decrease  in  the  number  of  leukocytes,  and  the  presence  of  a 
large  number  of  nucleated  red  corpuscles,  normoblasts,  megalo- 
blasts,  and  microblasts. 

Gastric  Ulcer. — In  the  old  chronic  forms  of  ulceration  the  blood 
usually  shows  the  changes  of  a  secondary  anemia,  as  in  chronic 
gastritis. 

In  ulcers  of  recent  origin  the  blood  may  show  no  variations 
from  the  normal,  or  it  may  show  the  characteristic  changes  of 
chlorosis,  viz.,  nearly  a  normal  number  of  red  corpuscles  with 
a  considerable  decrease  in  the  percentage  of  hemoglobin. 

After  hemorrhages,  the  changes  are  those  common  to  loss  of 
blood  from  any  part  of  the  body — a  decrease  in  the  red  corpuscles 
and  hemoglobin,  an  increase  of  the  leukocytes  for  a  few  days,  and 
the  presence  of  normoblasts  in  the  blood. 

In  ulcer,  digestion  leukocytosis  occurs,  a  point  of  some  value  in 
the  differential  diagnosis  between  ulcer  and  cancer. 

Cancer  of  the  Stomach. — In  the  early  stages  the  changes  may  be 
simply  those  of  secondary  anemia.  In  the  later  stages,  when  the 
cachexia  becomes  apparent,  the  blood  changes  are  rather  character- 
istic. There  is  a  marked  decrease  in  the  number  of  red  corpuscles 
and  in  the  amount  of  hemoglobin,  the  former  being  often  between 
one  and  two  million,  the  latter  from  20  to  30  per  cent.     There  are 


380  THE    BLOOD    AND    URINE    IN    STOMACH    DISEASES. 

often  a  number  of  nucleated  red  corpuscles,  both  normoblasts 
and  megaloblasts.  The  red  corpuscles  may  show  variations  in 
size,  averaging  smaller  than  normal,  often  with  an  exquisite  poikilo- 
cytosis.  A  leukocytosis  is  usually  present,  varying  greatly  in  its 
intensity.  There  is,  with  rare  exceptions,  no  digestion  leuko- 
cytosis. 

In  dilatation  of  the  stomach  from  benign  causes,  the  changes  are 
simply  those  of  secondary  anemia,  the  alterations  being  propor- 
tional to  the  disturbances  of  nutrition. 

THE  GASES  OF  THE  STOMACH. 

Under  normal  conditions  the  stomach  contains  a  mixture  of 
gases,  derived  in  part  from  air  swallowed  with  the  food,  in  part  from 
chemical  and  fermentative  processes  in  the  stomach,  and  possibly 
from  a  small  amount  of  COo  eliminated  from  the  blood  flowing 
through  the  gastric  mucosa.  The  contents  of  a  normal  stomach, 
removed  at  the  height  of  digestion,  and  placed  in  a  fermentation 
tube  at  the  body  temperature,  exhibit  for  several  days  only  slight 
gas  formation,  this  occurring  only  when  the  free  HCl  has  been 
nearly  or  completely  neutralized  by  the  food  products.  After 
this,  fermentation  and  putrefaction  proceed  as  usual  in  fluids  rich 
in  proteid  and  carbohydrate  material. 

Under  pathological  conditions,  such  as  marked  dilatations  with 
stenosis,  especially  when  due  to  malignant  disease,  the  case  is 
altered.  The  food,  which  usually  contains  a  variable  number  of 
bacteria,  is  not  properly  sterilized  in  the  stomach  on  account  of  the 
partial  deficiency  or  absence  of  HCl,  and  it  remains  for  a  long  time 
in  the  stomach  ;  in  addition,  it  is  not  subjected  to  a  normal  peris- 
talsis. The  requisite  conditions  for  an  abundant  bacterial  growth 
are  thus  present,  viz.,  an  animal  fluid  (containing  both  carbohydrates 
and  animal  proteids),  heat,  and  moisture. 

Various  gases  have  been  found  in  the  stomach  in  such  conditions, 
among  which  may  be  named  acetylene,  hydrogen,  carbon  dioxid, 
nitrogen,  oxygen,  marsh  gas  (CH^),  and  sulphuretted  hydrogen. 

The  question  of  the  special  variety  of  gas  is  not  of  as  much  im- 
portance as  that  of  the  formation  of  any  gas.  Accurate  gas  analyses 
have,  up  to  the  present  time,  yielded  little  of  diagnostic  value 
and  from  their  difficulty  will  seldom  be  attempted  by  the  general 
practitioner. 

The  presence  of  combustible  gases  in  dilated  stomachs  has  been 


TESTS    FOR    GASES    OF   THE    STOMACH.  38 1 

first  demonstrated  by  G.  Hoppe-Seyler  ("  Verhandl.  d.  Congr.  f. 
innere  Medicin,  1892,"  S.  392)  and  F.  Kuhn  {ZeitscJir.  f.  klin.  Med., 
Bd.  XXI,  S.  572).  These  investigators  demonstrated  that  hydrogen, 
marsh  gas,  etc.,  could  be  formed  notwithstanding  the  presence  of 
a  considerable  amount  of  free  HCl.  The  influence  of  various 
antiseptic  agents  on  the  process  of  gas  formation  in  the  stomach 
has  been  carefully  investigated  by  F.  Kuhn,  whose  results  con- 
stitute an  important  practical  contribution  to  the  therapy  of 
gastrectasia. 

To  test  for  the  presence  and  amount  of  gas  formation,  the  freshly 
drawn  stomach  contents  are  well  mixed  and  broken  up  into  a  finely 
divided  state,  poured  into  a  fermentation  tube  (that  devised  by 
Einhorn  for  the  estimation  of  sugar  in  urine,  or  the  ureometer  of 
Doremus  may  be  used),  and  the  tube  (loosely  stoppered  with  cotton) 
placed  in  a  warm  oven  at  the  temperature  of  the  body.  If  none 
of  these  is  at  hand,  a  fair  substitute  may  be  improvised  by  filling  a 
large  test-tube  with  the  stomach  contents  and  inverting  over  a  small 
beaker  partially  filled  with  the  same  material,  allowing  the  lower 
end  of  the  test-tube  to  dip  into  the  stomach  contents  in  the  beaker, 
to  retain  the  fluid  in  the  tube  by  atmospheric  pressure. 

If  evolution  of  gas  take  place  within  a  few  hours  thepresumption 
is  that  we  have  to  deal  with  a  case  of  stenosis  of  the  pylorus  ;  and 
if,  at  the  same  time,  we  find  a  marked  formation  of  lactic  acid  and 
an  absence  of  HCl,  we  may  assume  that  it  is  a  case  of  malignant 
stenosis  of  the  pylorus  with  a  high  degree  of  dilatation. 

In  non-malignant  stenosis  we  find,  as  a  rule,  that  the  gas  forma- 
tion goes  on  rather  less  rapidly  and  is-not  associated  with  an  excess 
of  lactic  acid  as  in  malignant  stenosis. 

In  dilatation  unaccompanied  by  stenosis,  and  even  in  the  pres- 
ence of  small  quantities  of  free  HCl,  we  find  that  gas  is  formed; 
often,  however,  only  after  the  tube  has  been  allowed  to  stand  for 
several  days. 

The  gas  may  be  submitted  to  various  tests  to  determine  its 
character. 

A  few  c.c.  of  a  strong  solution  of  caustic  soda  are  placed  in  the 
lower  part  of  the  fermentation  tube  and  allowed  to  stand  for  some 
time.  If  the  gas  is  composed  partly  or  wholly  of  CO2,  it  will  be 
absorbed  by  the  alkali,  and  its  volume  percentage  may  be  read  off 
directly  by  the  decrease  in  volume  of  the  gas. 

A  small  amount 'of  the  gas  is  allowed  to  bubble  out  and  a  piece 


382  THE    BLOOD    AND    URINE    IN    STOMACH    DISEASES. 

of  filter-paper,  previously  dipped  in  a  solution  of  lead  acetate,  is 
held  in  the  gas  as  it  escapes.  If  any  sulphuretted  hydrogen  is 
present,  the  paper  will  turn  black,  due  to  the  formation  of  lead 
sulphid. 

A  portion  of  the  gas  may  be  tested  for  inflammability  by  allow- 
ing it  to  flow  out  as  before  and  attempting  ignition  by  holding  a 
lighted  match  to  it  as  it  escapes.  If  it  take  fire  or  give  a  slight 
explosion,  the  probabilities  are  that  hydrogen,  marsh  gas,  or 
acetylene  are  present. 

URINARY    CHANGES    IN    STOMACH    DISEASES. 

While  many  interesting  and  valuable  observations  upon  the  urin- 
ary alterations  in  stomach  diseases  have  been  made,  it  must  be 
stated  that,  up  to  the  present,  little  of  diagnostic  importance  has  been 
determined.  It  is  not  without  interest,  however,  to  take  a  short 
review  of  the  topics  so  far  as  it  concerns  the  subject  of  this  book. 

The  Amount. — So  long  as  appetite,  digestion,  and  absorption 
from  the  stomach  and  intestinal  tract  are  little  interfered  with,  there 
are  only  trifling  alterations  in  the  quantity  of  urine. 

The  quantity  of  urine  sinks  in  cases  of  vomiting;  as,  for  exam- 
ple, in  acute  gastritis  and  gastric  ulcer,  the  decrease  in  the  amount 
of  urine  being  in  an  almost  exact  ratio  to  the  amount  of  fluid  lost 
by  vomiting. 

It  is,  however,  in  marked  cases  of  gastric  dilatation  and  pyloric 
stenosis  that  the  greatest  decrease  in  the  amount  of  urine  is  noticed. 
In  well-marked  cases  of  dilatation  the  amount  of  urine  often  sinks  to 
from  300  to  500  c.c.  Under  these  conditions  a  continued  low 
quantity  is  an  unfavorable  prognostic  sign,  while  an  increase  indi- 
cates an  improvement  in  the  motor  function. 

The  specific  gravity  has  little  diagnostic  significance,  but,  in 
general,  has  about  the  same  value  as  the  amount  of  urine.  In 
cases  of  dilatation,  in  which  the  element  of  inanition  is  beginning 
to  be  a  factor  in  the  clinical  picture,  we  find  that  the  solids  of  the 
urine,  as  indicated  by  the  specific  gravity,  fall  ;  while  in  cases  in 
which  the  nutrition  is  well  preserved,  the  total  solids  of  the  urine 
approximate  the  normal  value. 

The  Reaction. — Bruce  Jones,  in  1819,  first  explained  the  well- 
known  relation  existing  between  the  secretion  of  gastric  juice  and 
the  reaction  of  the  urine.  After  a  meal  the  acidity  of  the  urine 
decreases,  often  becoming   neutral,  and,  occasionally,  alkaline   in 


TOTAL   ACIDITY    OF   THE    URINE    IN    GASTRIC    DISEASES.  383 

from  three  to  five  hours.  Subsequently  the  acidity  of  the  urine 
increases,  reaching  about  the  average  a  short  time  after  the  food 
has  been  propelled  from  the  stomach  into  the  intestines.  The 
range  of  variation  is  greater  following  a  full  meal  than  a  light 
repast,  so  that  a  greater  fall  in  the  acidity  is  found  after  dinner  than 
after  either  of  the  other  meals. 

This  phenomenon  Bruce  Jones  explained  upon  the  ground  of  a 
greater  alkalinity  of  the  blood,  as  a  consequence  of  abstraction 
from  it  of  acids  or  acid-forming  substances.  The  presence  of  an 
increased  alkalinity  of  the  blood  leads  to  increased  excretion  of 
alkalies  in  the  urine  and  a  diminished  acidity.  An  additional 
factor  may  be  the  presence  of  alkalies  or  of  alkaline  carbonates  in 
the  food,  which  neutralize  the  acidity  of  the  gastric  juice,  and  assist 
also,  after  absorption,  in  increasing  the  alkalinity  of  the  blood. 

From  these  physiological  facts  the  variations  of  the  reaction  in 
disease  are  easily  understood.  In  the  vomiting  of  ulcer,  if  profuse, 
a  large  amount  of  acid  is  withdrawn  from  the  system  ;  and,  in  some 
cases,  the  urine  may  exhibit  for  some  time  a  neutral,  or  even 
alkaline,  reaction.  In  cases  of  hyperacidity  of  the  gastric  juice,  in 
which  a  larger  quantity  of  acid  (than  normal)  is  withdrawn  from 
the  blood,  the  curve  of  urinary  acidity  undergoes  greater  varia- 
tion than  under  normal  conditions.  In  cases  in  which  there 
is  a  considerable  diminution,  or  a  total  absence  of  the  acid  secre- 
tion of  the  stomach,  this  variation  in  the  reaction  of  the  urine  does 
not  occur,  or  if  any  variation  does  take  place  it  is  less  marked  than 
under  normal  conditions.  Hence  it  will  be  seen  that  in  cases  of 
atrophic  gastritis,  severe  chronic  gastritis,  and  in  carcinoma  of  the 
stomach,  with  an  absence  of  HCl,  little  or  no  variation  in  the  acidity 
of  the  urine  occurs, — a  fact  that  may  be  of  some  importance  in  the 
differential  diagnosis  between  carcinoma  and  ulcer  of  the  stomach, 
especially  where  the  occurrence  of  hematemesis  or  bloody  stools 
contraindicates  the  use  of  the  stomach-tube. 

The  Chlorids. — The  amount  of  chlorin  depends  primarily 
upon  the  amount  of  food,  and,  with  it,  on  the  amount  of  chlorids 
absorbed  from  the  stomach.  The  amount  of  chlorids  present  in 
the  urine  is  also  in  an  inverse  ratio  to  the  amount  of  HCl  secreted 
by  the  stomach. 

In  ulcer  of  the  stomach,  associated  with  considerable  vomiting 
of  a  large  amount  of  highly  acid  gastric  juice,  a  considerable 
decrease  in  the  amount  of  urinary  chlorids  will  be  found,  as  also  in 
other  cases  of  vomiting:  in  which  a  large  amount  of  HCl  is  lost. 


384  THE    BLOOD    AND    URINE    IN    STOMACH    DISEASES. 

In  hyperacidity  without  vomiting,  the  amount  of  urinary 
chlorids  decreases  as  secretion  goes  on,  diminishing  in  well-marked 
cases  to  a  very  low  percentage,  increasing  again  as  absorption  from 
the  stomach  and  intestine  goes  on,  finally  reaching  the  highest 
part  of  the  chlorid  curve  five  or  six  hours  (sometimes  later)  after 
the  ingestion  of  the  meal. 

In  cases  of  anacidity  this  curve  of  urinary  chlorids  does  not 
occur,  no  fall  of  chlorids  occurring  after  the  meal,  a  slight  increase 
taking  place  as  the  absorption  of  the  food  goes  on. 

In  severe  cases  of  gastrectasia  with  pyloric  stenosis,  the  amount 
of  chlorids  in  the  urine  sinks  very  considerably,  the  decrease  being 
in  proportion  to  the  severity  of  the  affection.  An  increase  in  the 
amount  of  chlorids  without  a  corresponding  change  in  the  diet 
may  be  taken  as  a  symptom  of  improvement,  in  this  respect  being 
even  of  more  prognostic  importance  than  the  increase  in  the 
amount  of  urine  which  usually  occurs  at  the  same  time. 

Taken  in  connection  with  the  total  nitrogen  of  the  urine,  the 
amount  of  chlorids  may  be  of  assistance  in  determining  the  ques- 
tion of  a  benign  or  malignant  stenosis  of  the  pylorus. 

If  one  finds,  for  example,  in  the  urine  a  small  amount  of  chlor- 
ids and  a  proportionally  small  amount  of  nitrogen,  it  speaks  for  a 
simple  inanition,  a  benign  stenosis ;  but  if,  on  the  other  hand,  one 
finds  a  small  amount  of  chlorids  and  a  relatively  large  amount  of 
nitrogen,  it  speaks  for  the  presence  of  a  malignant  stenosis. 

The  Phosphates. — The  investigation  of  the  excretion  of  phos- 
phates in  stomach  diseases  has  yielded  little  in  the  line  of  diagno- 
sis as  yet.  The  deposit  of  basic  phosphates  in  the  freshly  voided 
urine  passed  after  meals  is  quite  frequently  seen  in  cases  of  hyper- 
acidity, though  the  same  change  may  also  occur  in  perfectly  healthy 
individuals.  The  deposit  of  the  basic  earthy  phosphates  in  these 
cases  is  due  to  the  alkaline  tide  spoken  of  in  the  paragraph  upon 
the  reaction  of  the  urine. 

In  hyperacidity,  according  to  Robin,  the  excretion  of  phosphoric 
acid  is  considerably  increased. 

According  to  F.  Miiller,  the  excretion  of  phosphates  is  increased 
in  cancer  of  the  stomach,  though  not  in  all  cases. 

Of  more  diagnostic  importance,  however,  is  the  relation  exist- 
ing between  the  excretion  of  nitrogen  and  phosphoric  acid.  Under 
normal  conditions  the  proportion  is  about  as  follows : 

N     :     PjOj     :  :      loo     :      17  to  20. 


SIGNIFICANCE    OF    PREFORMED    AND    ETHEREAL    SULPHATES.     385 

In  malignant  disease  in  general,  the  proportion  of  P2O5  rises, 
in  one  case  of  gastric  carcinoma,  recorded  by  Chas.  E.  Simon,  the 
relation  being  100  :  34. 

The  Sulphates. — Of  the  two  forms  in  which  sulphuric  acid 
occurs  in  the  urine,  the  preformed  sulphates  have  only  a  passing 
interest  as  being  a  measure  of  the  proteid  metabolism  going  on  in 
the  system ;  while  the  ethereal  sulphates  have  a  more  direct  bear- 
ing, as  they  seem  to  be  formed  chiefly  b}-  putrefactive  changes 
within  the  intestine.  Asa  normal  secretion  of  HCl  and  a  normal 
motility  seem  to  be  the  chief  checks  upon  intestinal  putrefaction, 
it  can  be  readily  seen  that  in  cases  of  sub-  or  anacidity,  especially 
when  associated  with  an  impaired  motility,  the  putrefactive  changes 
in  the  intestine  are  increased  and  lead  to  an  increased  formation 
and  excretion  of  the  ethereal  or  combined  sulphates. 

In  expressing  an  opinion  as  to  the  condition  of  the  stomach 
from  the  amount  and  proportion  of  the  ethereal  sulphates,  care 
must  be  taken  to  exclude  any  intestinal  or  peritoneal  troubles, 
which  would,  by  themselves,  have  a  tendency  to  increase  the 
amount  of  putrefaction  in  the  intestine. 

Under  normal  conditions  the  amount  of  the  total  sulphuric  acid 
is  from  two  to  three  gm.,  increasing  under  a  meat  diet,  decreasing 
under  a  vegetable  diet ;  the  amount  of  ethereal  sulphuric  acid  being 
from  two  to  three  decigrams. 

The  average  normal  ratio  between  the  preformed  and  ethereal 
sulphuric  acid  is  as  ten  is  to  one,  the  proportion  being  stated,  as  a 
rule,  as  follows : 

A     :     B     :  :      10     :      I 

In  cases  of  nervous  anacidity  with  periods  of  normal  secretion,  it 
may  assist  in  forming  an  opinion  as  to  the  severity  of  the  case 
to  find  a  normal  ratio  of  the  sulphates.  In  a  case  of  anacidity 
due  to  some  organic  trouble,  the  amount  of  ethereal  sulphates  will, 
as  a  rule,  be  increased,  and  the  ratio,  instead  of  being  one  to  ten,  may 
be  increased  to  a  marked  degree,  in  some  cases  reaching  nearly 
equal  amounts. 

Indoxyl-sulphate  of  potassium  has,  for  the  most  part,  the  same 
significance  as  an  excessive  amount  of  ethereal  sulphates  or  an 
increase  in  their  ratio. 

This  chromogen  of  the  urine  is  a  product  of  the  putrefactive  bac- 
teria of  the  intestinal  canal.     As  the  result  of  their  action  upon  the 


386  THE    BLOOD    AND    URINE    IN    STOMACH    DISEASES. 

proteid  bodies  of  the  intestinal  canal,  indol  is  produced  from  which, 
by  successive  oxidations,  indigo-blue  is  formed.  This,  by  combi- 
nation with  the  elements  of  sulphuric  acid  and  potassium,  forms 
the  substance, — indoxyl-sulphate  of  potassium,  or  indican. 

Owing  to  the  fact  that  certain  species  of  bacteria  may  be  present 
which  do  not  form  indol,  the  absence  or  presence  of  this  body  in 
normal  amounts  in  the  urine  does  not  prove  the  absence  of  putre- 
factive changes  in  the  intestinal  canal. 

Recent  observations  of  Charles  E.  Simon  {Joe.  cit.)  show  that 
indican  is  present  in  excess  in  the  urine,  in  cases  of  marked  sub- 
acidity,  anacidity,  gastric  carcinoma,  stenosis  of  the  pylorus  from 
any  cause,  and  also  in  cases  of  gastric  ulcer  with  hyperacidity. 

Careful  study  of  a  series  of  cases  of  gastric  diseases  with  relation  to 
the  urine  seems  to  show  that  those  cases  of  gastric  disease  with  a 
marked  increase  in  the  amount  of  indican  are  those  which  are  asso- 
ciated with  a  lack  of  motility. 

It  must  be  said,  however,  that  the  ratio  of  the  ethereal  to  the 
preformed  sulphates  is  a  better  index  to  amount  of  decomposition 
in  the  intestinal  canal. 

Indigo-red,  also  called  urrhodin,  has  essentially  the  same  signifi- 
cance as  indigo-blue  or  indican. 

Urea  and  Nitrogen. — The  amount  of  nitrogen  eliminated  in  the 
urine  may  come  direct  from  the  food  ingested  or  from  the  nitro- 
genous metabolism  of  the  body. 

In  general  it  may  be  said  that  those  diseases  which  are  attended 
with  impaired  digestion  of  proteid  foods  are  attended  with  a 
decrease  in  the  amount  of  nitrogen  eliminated  in  the  urine.  In  the 
cachexia  which  results  from  cancer  of  the  stomach,  the  elimination 
of  nitrogen  is  greater  than  is  the  elimination  in  simple  inanition  of 
the  same  degree  of  severity. 

There  is  at  present  no  explanation  of  this  fact  unless  it  be  due  to 
some  product  of  the  tumor  itself,  which  is  eliminated  by  the  urine, 
or  to  the  increased  metabolism  of  the  body  resulting  from  some 
product  of  the  neoplasm.  This  theory  as  to  the  production  of  some 
poisonous  substance  by  the  tumor  itself  is  supported  by  the  fact 
that  even  small  carcinomata,  situated  in  a  part  of  the  body  where 
they  in  no  way  influence  the  bodily  functions,  give  rise  occasionally 
to  an  increase  in  the  elimination  of  nitrogen  by  the  urine. 

The  proportions  of  the  various  nitrogenous  bodies  in  the  urine, 
according  to  the  few   published  observations,  depart  considerably 


SIGNIFICANCE    OF    ACETONEURIA    AND    PEPTONURIA.  38/ 

from  the  normal  in  carcinoma.  In  normal  urine  the  nitrogenous 
matter  is  divided  about  as  follows:  Urea,  96  percent.;  uric  acid,  1.8 
cent.;  ammonia,  1.2  per  cent. ;  and  extractive  matters,  0.6  per  cent. 
to  0.8  per  cent. 

In  cases  of  carcinoma  examined  by  Topfer  the  proportions  were 
as  follows  :  Urea  as  low  as  80  per  cent. ;  uric  acid,  one  to  five  per 
cent. ;  ammonia,  0.2  per  cent,  to  13  per  cent.,  and  extractive  matters 
13  per  cent,  to  23  per  cent.  Von  Noorden  also  found  the  ammonia 
increased  (10.2  per  cent,  to  13.9  per  cent.). 

It  is  thus  seen  that  in  these  cases  there  is  a  relative  decrease  in 
the  amount  of  urea  with  or  without  a  rise  in  the  amount  of  uric 
acid,  and  a  considerable  increase  in  the  relative  amounts  of  am- 
monia and  extractives. 

Acetone  and  Diacetic  Acid. — Acetone  and  diacetic  acid  occur 
in  the  urine  in  various  disturbances  of  the  digestive  tract,  affecting 
both  the  stomach  and  intestines,  and,  according  to  Lorenz,  their 
occurrence  is  not  infrequent. 

Acetone  occurs  frequently  in  the  digestive  disturbances  of  chil- 
dren, and  is  by  some  authors  considered  as  the  cause  of  the  con- 
vulsions which  so  often  accompany  these  derangements. 

Acetone  is  found  in  the  urine  in  increased  amounts  in  cases  of 
inanition  and  in  cachectic  conditions,  and  to  this  fact  may  be 
assigned  the  occurrence  of  acetone  in  increased  amount  in  cases  of 
cancer  and  of  dilatation  of  the  stomach. 

In  general  it  may  be  said  that  the  increase  in  amount  of  acetone 
and  the  presence  of  diacetic  acid  simply  indicate  an  increase  in  al- 
buminous disintegration. 

Albumin. — Albumin  is  not  of  infrequent  occurrence  in  cases 
of  gastric  disturbances.  It  may  be  the  result  of  any  severe  stomach 
disease. 

Von  Noorden  found  albumin  with  relative  frequency  after  the 
onset  of  severe  gastric  pains,  such  as  occur  at  intervals  in  ulcer  of 
the  stomach  and  also  after  profuse  hematemesis.  In  cases  of  can- 
cer of  the  stomach,  especially  in  the  later  stages,  albumin  is  found, 
either  regularly  or  temporarily,  in  a  large  proportion  of  cases. 

Peptonuria. — The  question  as  to  the  occurrence  of  peptone  in 
the  urine — as  the  word  peptone  is  now  employed — is  not  definitely 
settled. 

Under  certain  conditions  the  urine  fails  to  react  to  the  ordinary 
tests  for  albumin,  such  as  Heller's  nitric  acid  test,  Purdy's  acetic 


388  THE    BLOOD    AND    URINE    IN    STOMACH    DISEASES. 

acid  and  potassium  ferrocyanid  test,  and  the  boiling  test ;  while  it 
certainly  contains  some  form  of  proteid  which  reacts  to  the  biuret 
test. 

The  question  whether  this  is  a  secondary  albumose,  pure  pep- 
tone, or  a  mixture  of  the  two,  is  of  minor  importance  from  a  clinical 
standpoint.  Recent  investigations  show  that,  in  the  course  of 
absorption,  peptones  are  acted  upon  by  the  epithelium  of  the  gastro- 
intestinal tract  and  reconverted  into  the  coagulable  proteids. 

This  theory  renders  the  occurrence  of  peptonuria  in  the  course 
of  gastric  ulcer,  carcinoma  of  the  stomach,  erosions  of  the  mucosa, 
and  ulceration  of  the  intestine  easy  of  comprehension.  The  occur- 
rence of  these  bodies  in  such  diseases  is  general  in  this  class  of 
cases,  though  many  observers  have  failed  to  demonstrate  them  in 
all  cases. 

Ferments. — Under  normal  conditions  the  urine  contains  a  vari- 
able quantity  of  pepsin  and  rennin  ferment.  The  maximum  excre- 
tion of  pepsin  is  found  from  four  to  six  hours  after  meals.  Pepsin 
is  often  found  to  be  decreased  or  entirely  absent  in  the  urine  in 
cases  of  cancer  of  the  stomach,  and  would  probably  be  found,  in  the 
course  of  extended  observations,  to  vary  in  an  exact  ratio  to  the 
amount  of  pepsin  formed  by  the  stomach. 

Rennin  is  found  to  undergo  the  same  variations  as  pepsin,  and 
its  variations  have  the  same  clinical  significance. 

Ehrlich's  Diazo  Reaction. — The  presence  or  absence  of  this 
color  reaction  of  the  urine  was  formerly  thought  to  be  of  great 
diagnostic  importance  for  the  recognition  and  differentiation  of 
typhoid  fever.  In  the  two  diseases  of  the  stomach  (acute  and 
phlegmonous  gastritis)  with  which,  in  its  earlier  stages,  typhoid 
fever  might  be  confounded,  it  would  be  of  great  value  were  its 
accuracy  undoubted.  Quite  an  extended  experience  with  this  test, 
used  on  all  patients  entering  the  hospital  for  several  months, 
showed  conclusively  that  it  could  not  be  relied  upon  as  a  dif- 
ferential test,  several  patients  giving  a  typical  reaction  whose  his- 
tory before,  during,  and  after  the  examination  excluded  typhoid 
absolutely.  On  the  other  hand,  even  in  typhoid  fever  the  reaction 
frequently  is  absent,  so  that  any  absolute  deductions  as  to  the  dis- 
ease from  this  reaction  are  apt  to  be  misleading. 


PART  THIRD. 

THE   GASTRIC  CLINIC. 


CHAPTER   I. 

ACUTE    GASTRITIS. 

Simple  Acute  Gastritis. — Phlegmonous  or  Puritlent  Gastritis. — S^ip- 

purative  Inflammation  of  the  Gastric  Mucosa. — Abscess  of  the 

Stomach. — Infectious  Gastritis. — Gastritis  Mycotica  or 

Parasitaria.  —  Gastritis    Diphtherica    and    Crou- 

posa. —  Toxic  Gastritis. — Gastritis  Ve?tenata. 

Gastritis  is  a  collective  or  generic  term  which  comprehends  all 
inflammatory  processes  of  the  stomach  proper,  including  the  so- 
called  catarrh  of  the  superficial  layer  of  columnar  epithelium,  the 
inflammation  of  the  glandular  parenchyma  and  interstitial  connec- 
tive tissue,  the  purulent  infiltration  of  the  submucosa  and  muscu- 
laris,  and  also  the  penetrating  excoriations  of  corrosive  poisons. 

It  is  natural  that  these  manifold  morbid  conditions  should  pre- 
sent considerable  variations  in  etiology  as  well  as  in  the  intensity 
of  the  symptoms.  It  is  almost  impossible  to  draw  a  sharp  limit 
separating  the  simple  superficial  catarrhs  from  the  deeper,  pene- 
trating inflammations.  Penzoldt  suggests  the  line  between  mucosa 
and  submucosa. 

We  may  designate  as  simple  gastritis  that  inflammation  of  the 
gastric  mucosa  which  involves  not  only  the  superficial  columnar 
epithelium,  but,  as  a  rule,  the  glandular  parenchyma.  This  con- 
dition may  occur  in  an  acute  and  in  a  chronic  form,  and  under  each 
classification — the  acute  and  the  chronic  gastritis — one  may  arrange 
two  subdivisions:    (i)  the  primary  and  (2)  the  secondary  gastritis. 

We  therefore  have  (i)  the  acute,  simple,  primary  gastritis,  which 
occurs  as  the  original  disease  ;  and  (2)  the  acute  secondary  gastritis, 
known  as  the  gastritis  sympathica  acuta,  which  occurs  not  as  the 
original  disease,  but  as  a  frequent  accompaniment  of  numerous 
acute  febrile  disorders.    All  the  exanthematous  infectious  diseases — 

389 


390  ACUTE    GASTRITIS. 

measles,  scarlatina,  variola,  typhus  and  typhoid  fevers,  puerperal 
fever,  pyemia,  dysentery,  croup,  and  diphtheria — are  known  to  effect 
pathological  changes  in  the  gastric  mucosa  directly,  or  to  influence 
it  detrimentally  by  reflex  nervous  action  (Hoppe-Seyler,  "  Allge- 
meine  Biologic,"  1877,  p.  242). 

There  is  a  very  plausible  desire  evident  in  some  recent  works 
on  the  subject  to  avoid  the  name  stomach  or  gastric  catarrh,  because 
the  word  catarrh  has  reference  to  a  superficial  inflammation,  but  in 
gastritis  we  are  dealing  also  with  parenchymatous  inflammation. 
Penzoldt  uses  the  expression  "simple  gastritis"  for  an  inflammation 
reaching  no  deeper  than  the  submucosa  [gastritis  simplex) ;  for  the 
penetrating  results  of  suppurative  or  purulent  inflammation  he  uses 
the  term  "grave  gastritis"  [gastritis  gravis).  He  does  not  favor 
the  terms  "  toxic  "  and  "  infective  gastritis,"  for  to  a  certain  extent 
all  forms  of  this  disease  are  toxic  and  infective,  and  in  his  book, 
"  Specielle  Therapie  innerer  Krankheiten,"  vol.  iv,  p.  320,  he  dis- 
cusses only  (i)  simple  and  grave  acute  gastritis,  (2)  chronic  gastritis, 
and  (3)  purulent  or  suppurative  gastritis.  Fleischer  ("  Specielle 
Therap.  u.  Pathol,  d.  IVIagen-  u.  Darmkr.,"  S.  793)  describes  (i)  sim- 
ple acute,  (2)  secondary  or  sympathetic  acute,  (3)  phlegnionous  or 
purulent,  (4)  toxic,  (5)  diphtheritic,  croupous,  mycotic,  parasitic,  (6) 
chronic  gastritis.  Excepting  those  forms  mentioned  by  Fleischer 
under  group  5,  Boas  describes  all  of  these  in  separate  chapters. 

Ewald  mentions  and  describes  all  of  these  forms,  and  subdivides 
the  suppurative  inflammation  (the  gastritis  pJilegmonosa  piiridenta) 
into  an  idiopathic  primary  and  a  metastatic  secondary  form,  Sidney 
Martin's  treatise  on  "  The  Organic  and  Functional  Diseases  of  the 
Stomach  "  deals  with  the  symptomatology,  pathology,  and  treatment 
of  acute  and  chronic  gastritis  in  one  chapter  (chap,  viii),  and  then 
goes  on  to  speak  of  toxic  and  infective  gastritis  in  the  next  chapter 
(chap.  ix).  Albert  Mathieu,  of  Paris,  briefly  mentions  acute  and 
chronic  gastritis,  and  the  varying  amount  of  mucus  and  acid  accom- 
panying these  diseases ;  none  of  the  other  forms  are  referred  to. 
(New  York  edition.) 

Rosenheim  ("  Pathol,  u.  Therap.  d.  Krankh.  des  Verdauungs- 
apparates,"  p.  99)  describes  gastritis  as  acute,  simple,  phlegmonous, 
toxic,  diphtheritic,  and  chronic.  Einhorn  approaches  the  simple 
classification  of  Penzoldt,  and  divides  acute  gastritis  into  (i)  simple, 
[2)  phlegmonous,  and  (3)  toxic,  and  then  proceeds  to  the  consider- 
ation of  chronic  g-astritis. 


CLASSIFICATION,    NATURE,    AND    CONCEPT.  39 1 

Alois  Pick  describes  (i)  acute,  (2)  infectious,  (3)  phlegmonous, 
(4)  toxic,  (5)  parasitic,  and  (6)  chronic  gastritis  ("  Vorlesungen  iiber 
Magen-  u.  Darmkrankheiten,"  S.  73);  and  Fleiner  ("  Lehrbuch  d. 
Krankheiten  d.  Verdauungsorgane  ")  gives  an  account  of  (i)  gas- 
tritis catarrhalis  acuta,  for  which  he  also  uses  the  name  gastricismus  ; 

(2)  gastritis  toxica  ;  (3)  interstitial  suppurative  gastritis,  stomach  ab- 
scess and  stomach  phlegmone,  or  gastritis  phlegmonosa  or  inter- 
stitialis,  or  submucosa  purulenta,  or  also  Hnitis  suppurativa;  (4) 
mycotic  gastric  inflammations;   (5)  chronic  gastritis. 

Osier,  in  his  new  "  Principles  and  Practice  of  Medicine,"  pp.  348 
and  359,  considers  (i)  acute  simple,  (2)  phlegmonous  or  acute  sup- 
purative, (3)  toxic,  (4)  diphtheritic  or  membranous,  (5)  mycotic  or 
parasitic,  (6)  chronic  gastritis.  Under  the  latter  he  gives  a  special 
paragraph  to  the  chronic  forms  with  extreme  connective-tissue  pro- 
liferation and  increase  in  thickness  of  the  submucosa  and  mus- 
cularis,  under  the  name  of  sclerotic  gastritis. 

These  references  are  sufficient  to  demonstrate  the  discrepancy 
existing  in  later  works  concerning  the  separate  and  distinct  recog- 
nition of  the  various  forms  of  this  disease,  and  that  a  more  uniform 
classification  would  be  desirable. 

In  accordance  with  Penzoldt,  this  treatise  will  describe  only  (i) 
simple  acute  gastritis,  (2)  simple  chronic  gastritis,  and,  separately, 

(3)  the  forms  in  which  the  element  of  pus  formation  is  a  factor — the 
suppurative  gastric  inflammations;  and  in  a  supplement  the  forms 
due  to  toxic  or  corrosive  agents,  and  the  remaining  very  rare  varie- 
ties, may  be  appropriately  described. 

Nature  aitd  Concept. — One  should  be  very  careful  not  to  diagnose 
every  temporary,  transient  gastric  disturbance  as  acute  gastritis,  nor 
a  prolonged  loss  of  appetite,  with  eructations,  coated  tongue,  and  no 
other  demonstrable  signs  and  symptoms,  as  chronic  gastritis ;  as  Pen- 
zoldt correctly  says,  this  is,  in  the  majority  of  such  cases,  neither  jus- 
tifiable nor  conducive  to  the  scientific  development  of  diagnosis.  We 
can  agree  with  him  in  the  opinion  that  it  is  inconceivable  that  all  the 
functional  and  anatomical  changes  which  one  is  accustomed  to  find 
in  acute  inflammations  in  other  tissues,  should  really  be  present 
in  every  brief  digestive  disturbance  after  dietetic  errors,  alcoholic 
abuse,  etc. 

We  could  not  designate  a  brief  irritation  of  the  nose,  with  sneez- 
ing, secretion  of  mucus,  and  hoarseness,  lasting  several  hours,  as 
nasal    catarrh.     By  catarrh  of  the  air  passages  we  understand    a 


392  ACUTE    GASTRITIS. 

more  lasting  affection,  with  a  somewhat  typical  course,  and  more 
permanent  changes,  of  both  a  structural  and  functional  nature,  in 
the  mucosa.  Indeed,  Sidney  Martin  very  appropriately  considers 
these  functional,  lighter  forms  of  gastric  disturbance  in  separate 
chapters,  and  classifies  them  under  (i)  gastric  irritation,  and  (2)  gas- 
tric insufficiency.  Functional  disorders,  then,  are  irregularities  of 
gastric  motility,  absorption,  and  secretion,  and  also  of  the  innerva- 
tion and  vascular  supply,  in  which  organic  diseases  of  the  stomach 
— ulcer,  gastritis,  neoplasm,  etc. — are  absent.  It  can  not  with  cer- 
tainty be  stated  that  all  histological  changes  are  absent  in  functional 
disorders  ;  at  least,  not  in  functional  disorders  of  secretion.  We 
have  become  convinced  of  certain  changes  in  the  acid  and  ferment 
cells  that  are  apparently  quite  constant. 

Ever  since  Beaumont's  pioneer  observations  it  has  been  known 
that  every  severe  inflammatory  irritation  of  the  gastric  mucosa 
produces  an  alteration  in  the  gastric  secretion,  the  quantity  and 
effectiveness  of  which  is  much  reduced;  it  is  known,  furthermore, 
that  the  impairment  of  one  function  of  the  stomach,  as  a  rule, 
rapidly  involves  that  of  another.  The  inner  lining  of  the  stomach 
can  not,  in  the  true  anatomical  meaning  of  the  word,  be  called  a 
mucous  membrane,  because  it  is  devoid  of  one  of  the  essential  attri- 
butes of  a  mucous  membrane — the  mucous  glands.  The  mucus  of 
a  normal  stomach  is  surprisingly  small  in  amount,  and  owes  its 
origin  not  to  glands  but  to  mucoid  degeneration  of  the  superficial 
columnar  epithelial  cells. 

As  this  cylindrical  epithelium  continues  down  into  the  alveoli 
of  the  peptic  tubules  without  any  distinct  border  line,  all  irritants 
striking  the  former  must  of  necessity  affect  the  parietal  or  border 
cells  as  well  as  the  chief  cells  of  the  gland-duct.  It  is  characteris- 
tic of  the  pathology  of  gastric  digestion  that  impairment  of  one 
important  function,  or  rather  of  one  of  the  many  physiological  pro- 
cesses of  which  the  digestive  act  is  composed,  soon  creates  sympa- 
thetic disturbance  in  the  remaining  functions,  so  that  the  clinical 
picture  of  an  acute  or  chronic  gastritis  is  that  of  a  combination  of 
disturbances. 

It  is  not  established,  nor  very  essential,  which  function  suffers 
first,  but  probably  in  most  cases  a  derangement  of  secretion  starts 
the  morbid  series,  and  the  remaining  functions  follow  in  the  affec- 
tion. For  example  :  If  by  ingestion  of  food  which  is  already  in  a 
state  of  fermentation  an  acute  gastritis  has  been  induced,  the  reduc- 


PATHOLOGICAL    PHYSIOLOGY    OF    GASTRITIS.  393 

tion  in  the  amount  of  hydrochloric  acid  produces  a  hindrance,  not 
only  in  the  normal  chemistry  of  the  stomach,  but  resorption  and 
motility  are  also  very  soon  retarded.  This  pronounced  subacidity 
has  in  its  consequence  an  imperfect  digestion  of  the  proteids,  so 
that  very  small  amounts  of  acid  albumin  and  hemialbumose  are 
detectable  in  the  vomit,  and  peptone  is  found  in  traces  onh-.  A 
further  step,  then,  is  that  these  undigested  proteids  continue  to  re- 
main in  the  stomach  longer  than  with  normal  proteolysis.  This 
means  a  much  more  prolonged  burdening  of  the  gastric  walls  ;  the 
stomach  does  not  gain  sufficient  rest  in  which  to  prepare  itself  for 
the  demands  of  the  following  meal ;  the  distention  by  the  weight  of 
the  food  lasts  longer.         • 

On  the  other  hand,  much  more  of  the  carbohydrates  will  in  this 
subacidity  be  converted  into  soluble  starch,  maltose,  and  dextrose, 
than  with  a  normal  secretion  of  hydrochloric  acid.  With  the  pro- 
gressing stagnation  and  putrefaction  of  proteids,  these  products  of 
starch  inversion  mean  more  ready  food  for  bacteria,  which  are 
constantly  introduced  with  the  saliva,  and,  finding  in  the  moisture 
and  suitable  temperature  of  the  gastric  contents  congenial  condi- 
tions for  their  development,  the  danger  of  progressive  decomposi- 
tion is  very  great.  The  toxic  products  of  this  carbohydrate  and 
proteid  decomposition  are  irritants  to  the  mucosa,  and  increase  the 
already  existing  inflammation. 

When  this  inflammation  has  reached  a  certain  stage,  an  inflam- 
matory edema  of  the  muscular  layers  sets  in,  effectually  destroying 
the  motility,  and,  simultaneously  (as  in  most  all  serous  and  mucous 
inflammations),  an  alkaline  transudate  exudes  into  the  mucosa,  neu- 
tralizing the  last  vestige  of  hydrochloric  acid  that  may  yet  be 
secreted.  Lactic,  but\-ric,  and  acetic  acid  are  evoh'ed  from  the  fer- 
menting carbohydrates,  and,  further  on,  H0CO3  and  H. 

When  these  gases  begin  to  expand,  and  the  already  impaired 
motility  can  not  expel  them  by  eructation,  the  stomach  is  still 
further  distended.  The  normal  hydrochloric  acid  not  only  acts  as 
an  antiseptic  and  antifermentative,  but,  as  we  know,  undoubtedly 
brings  about  energetic  peristalsis,  which  effects  a  thorough  mixing 
of  the  ingesta,  and,  frequently,  repeated  contact  and  friction  with 
those  portions  of  the  secretory  membrane  whose  glands  produce 
the  hydrochloric  acid  and  ferments.  This  mixing  and  triturating 
peristalsis  is  at  the  same  time  a  most  essential  stimulus  to  absorp- 
26 


394  ACUTE    GASTRITIS. 

tion,  and  eventually  effects  the  timely  expulsion  of  the  chyme  into 
the  duodenum. 

With  impaired  motility,  therefore,  the  food  masses  remain  too 
long  in  one  and  the  same  place.  An  intimate  contact  of  the  in- 
gesta  with  the  membrane,  as  is  produced  by  healthy  peristalsis,  is 
essential  for  normal  stimulation  to  continued  secretion;  hence,  the 
secretion  of  the  oxyntic  and  ferment  cells,  already  damaged  by  in- 
flammatory infiltration,  soon  ceases  entirely.  Resorption  is  not 
only  impaired  by  absence  of  intimate  contact  with  ingesta,  but  by 
the  fact  that  the  epithelial  surface  is,  in  the  various  forms  of  gas- 
tritis, covered  with  a  tough  glassy  mucus,  epithelial  detritus,  and 
sometimes  pus.  In  addition  to  this,  one  must  not  overlook  the 
element  of  the  effects  of  the  inflammatory  changes  on  the  rate, 
tonicity,  quality,  and  quantity  of  the  circulation  on  all  of  the  gastric 
functions. 

The  damaging  effects  of  inflammation  might  be  partly  made  up 
again  by  a  healthy  peristalsis,  but,  as  this  is  not  present,  resorption 
and  secretion  are  inhibited.  The  suspension  of  the  resorption  must 
be  looked  upon  as  an  act  of  self-protection,  as  there  are  nothing 
but  poisons  to  absorb  in  these  conditions.  There  is,  fortunately, 
no  excessive  formation  of  peptone,  as  this  is  prevented  by  the 
subacidity.  We  say  "  fortunately,"  because  it  would  simply  be  food 
for  bacteria.  So  it  is  evident  that,  in  an  acute  gastritis,  there  are 
numerous  concurrent  deleterious  elements  and  changes  which 
are  essentially  similar  to  those  of  most  light  and  severe  gastric  in- 
flammations. 

The  clinical  picture  is  a  very  manifold  one,  as  in  the  individual 
cases  one  may  observe  first  one  and  then  another  function  that  is 
most  seriously  damaged.  It  is  natural  to  observe  exceptions  from 
the  rule  :  thus,  in  prolonged  anacidity  we  may  find  cases  in  which 
the  motility  is  unimpaired,  which  of  course  favors  intestinal  diges- 
tion by  timely  evacuation  of  the  chyme,  so  that  even  the  symptoms 
of  dyspepsia  may  be  lacking. 

Etiology. — In  the  majority  of  cases,  acute  simple  gastritis  is 
caused  by  errors  in  diet.  Irritation  may  be  caused  by  quantity  as 
well  as  by  quality  of  the  food.  Decomposed  articles  of  liquid  or  solid 
nature  will  set  up  inflammation  through  the  bacteria  they  contain. 
These  germs  must  not  be  thought  to  invade  the  mucosa  proper  in 
all  cases  ;  they  exert  effects  by  their  action.     Ewald  {loc.  cit.)  says 


ETIOLOGY.  395 

he  has  never  found  bacteria  in  the  gastric  tissues  in  these  cases. 
Spoiled  or  decomposed  meat,  fish,  or  vegetables,  cheese,  wine,  cider 
or  beer  that  has  not  completed  its  fermentation,  infected  milk,  and 
impure  pond  water  have  been  known  to  produce  severe  acute 
gastritis. 

Excessive  indulgence  in  perfectly  healthy  food  can  provoke  the 
trouble,  not  only  by  the  mechanical  distention  and  irritation  which 
are  caused  thereby,  but  by  the  inability  of  the  motor  power  to  move 
the  ingesta  about  and  to  expel  them  into  the  duodenum,  and  also  by 
the  deficiency  in  the  secretion  of  gastric  juice,  which  may  be  able 
to  digest  a  normal  but  not  an  excessive  amount  of  food.  The 
amount  that  can  be  digested  under  normal  conditions  without 
causing  acute  gastritis  will  naturally  vary  considerably  in  different 
individuals. 

Clieniical  Causes. — Among  these  ma}'  be  mentioned  quinin  salts 
in  large  doses  ;  all  metallic  salts,  particularh^  those  of  copper,  anti- 
mony, arsenic,  lead,  gold,  mercury,  and  silver ;  acids,  and  alkalies, 
unless  properly  diluted. 

We  have  observed  an  acute  gastritis  follow  the  use  of  two  gm. 
of  sodium  salicylate  three  times  daily,  and  feel  convinced  that  iodid 
of  potassium,  if  not  given  properly  mixed  with  food  (right  after 
meals),  may  lead  up  to  gastritis.  The  various  drugs  used  inter- 
nally for  gonorrhea — cubebs,  copaiba,  and  the  oil  of  sandalwood — 
may,  in  susceptible  individuals,  bring  about,  after  long  use,  a  condi- 
tion of  the  gastric  mucosa  in  which  acute  gastritis  is  readily  set  up. 

Psychic  Causes. — It  is  said  that  grief,  sorrow,  terror,  anger,  and 
even  excessive  joy  (?),  have  been  observed  to  produce  gastritis. 
Sexual  excesses,  particularly  in  neurasthenics,  are  on  record  as 
causes. 

Thermic  Causes. — Large  quantities  of  very  cold  or  very  hot  liquids, 
particularly  the  former,  can  produce  the  disease,  when  taken  in 
rapidly  when  the  body  is  in  an  o\'erheated  state. 

Mechanical  Causes. — It  is  possible  that  pieces  of  fish  bone,  &'g^ 
shells,  or  oyster  shells,  or  fruit  seeds,  if  accidentally  ingested,  may,  by 
mechanically  scratching  and  bruising  the  mucosa,  cause  a  gastritis. 
We  had  occasion  to  observe  a  singular  case  of  this  disease  in  a  profes- 
sional base-ball  player,  caused  by  a  blow  from  a  base-ball  pitched  with 
great  speed.  The  bruise  extended  from  the  xyphoid  cartilage  to 
the  left  hyprochondriac  region.  The  player  was  knocked  senseless, 
and,  after  partial  recovery,  vomited  a  meal,  which  he  had  taken  two 


39^  ACUTE    GASTRITIS. 

hours  before,  mixed  with  blood  and  much  mucus  ;  later  on  he 
vomited  some  milk  that  was  given  him,  and  on  being  tested  this 
vomit  was  alkaline. 

The  pain  was  so  severe  that  morphin  had  to  be  injected  hypo- 
dermically,  and  food  was  kept  out  of  his  stomach  altogether  for 
three  days,  during  which  period  he  was  fed  by  Boas'  nutrient 
enemata.  The  attack  lasted  two  weeks,  and  the  patient  made  a 
perfect  recovery. 

Predisposition. — Manassein  has  shown  that  fever  produced  experi- 
mentally in  dogs  which  he  had  made  anemic  by  depriving  them  of 
much  blood,  caused  considerable  suppression  of  the  secretion  of 
hydrochloric  acid.  Kussmaul,  Uffelmann,  Leube  and  von  den 
Velden  have  confirmed  this  subacidity  in  cases  of  fever  in  the 
human  being.  It  is  not  surprising,  therefore,  if  we  find  acute  gas- 
tritis developing  in  convalescents  from  severe  diseases;  also  in 
tuberculous,  cancerous,  and  syphilitic  patients.  Functional  gastric 
disturbances  predispose  to  acute  gastritis  as  well  as  pre-existing 
or  concomitant  diseases  of  the  heart,  lungs,  liver,  and  kidneys. 
Ewald  believes  in  hereditary  predisposition  to  gastritis,  as  some 
families  show  numerous  cases  of  the  trouble  in  spite  of  the  best 
care  they  take  of  their  stomachs. 

Idiosyncrasy. — It  is  a  very  perplexing  fact  that  some  persons  in 
good  health  acquire  acute  gastritis  after  eating  certain  articles  of 
food.  While  the  author  was  resident  physician  of  Bay  View 
Asylum,  Baltimore,  he  had  a  colleague,  a  perfectly  robust,  vigorous 
man,  who  was  not  at  all  neurasthenic,  who  developed  the  disease 
every  time  he  ate  oysters.  He  could  not  be  induced  to  eat  them 
after  he  had  established  the  causal  relation,  but  convinced  us  by 
consenting  to  an  experiment. 

Influence  of  Sex  and  Age. — Acute  gastritis  occurs  more  frequently 
in  men  than  in  women  ;  of  36  cases  observed  by  the  author,  of 
which  records  were  taken,  ten  occurred  in  females  and  26  in  males. 
Females  are  more  frequently  attacked  during  menstruation  and 
puerperium.  Old  persons  and  very  young,  feeble  children  are  more 
Hkely  to  be  attacked  than  those  in  middle  age.  In  nursing  infants 
a  very  slight  change  in  the  milk  may  be  enough  to  cause  it.  Ac- 
cording to  Booker,  of  Baltimore,  acute  gastritis  in  infants  is  accom- 
panied by  prolongation  of  the  time  that  the  milk  is  retained  in  the 
stomach,  at  times  over  five  hours.  The  gastric  contents  occa- 
sionally show  epithelial  and  pus  cells. 


SECONDARY   SYMPATHETIC    GASTRITIS.  39/ 

Rotch  ("  Pediatrics,"  p.  854)  holds  that  the  acute  form  is  more 
common  in  infants,  and  that  the  chronic  form,  while  it  does  occur 
in  them,  is  more  frequent  in  children  toward  puberty.  The  frequent 
attacks  of  gastritis  occurring  during  the  hot  summer  months  are 
undoubtedly  largely  due  to  the  consumption  of  unripe  fruit.  Bou- 
veret,  however  ("  Traite  des  Maladies  de  1'  Estomac,"  p.  384,  Paris, 
1893),  attributes  them  to  the  abusive  consumption  of  water.  Ac- 
cording to  Pick,  the  disease  has  been  observed  to  develop  after 
taking  cold. 

The  effect  of  fever  on  the  secretions  of  the  stomach  is  not  al- 
ways evident.  Edinger  found  the  secretion  of  hydrochloric  acid 
normal  in  five  cases  of  fever  ;  having  examined  hectic,  recurrent, 
intermittent,  and  typhoid  fever  patients  (L.  Edinger,  "Zur  Physiol, 
u.  Path.  d.  -Magens,"  De^itscJi.  ArcJiiv  f.  klin.  Medizin,  Bd.  xxix,  S. 
555).  G.  Klemperer  ("  Dyspepsie  d.  Phthisiker,"  Berlin,  klbi. 
WoclienscJir.,  1889)  and  Schetty  ("  Untersuch.  ii.  Magenfunction  bei 
Phthisis,"  Detitsch.  Archiv  f.  klin.  Med.,  Bd.  xliv,  S.  516)  confirm 
the  finding  of  Edinger.  Ewald  {loc.  cit.,  p.  301)  found  almost  nor- 
mal digestive  power  in  a  case  of  facial  erysipelas.  From  these 
studies  it  is  plain  that  not  in  all  cases  of  secondary  acute  gastritis 
can  we  attribute  the  stomach  affection  to  the  functional  disturbances 
which  the  primary  disease  produces  :  for,  in  the  first  place,  these  may 
be  entirely  absent ;  secondly,  the  frequency  of  the  gastritis  is  not 
at  all  dependent  upon  the  height  or  intensity  of  the  fever ;  thirdly, 
the  secondary  sympathetic  gastritis  may  set  in  concomitant  with 
the  fever  or  even  before  it,  ushering  in  the  main  infectious  symp- 
toms as  a  prodromal  affection. 

The  secondary  sympathetic  gastritis  is  therefore  more  likely  to  be 
originated  by  localization  of  the  specific,  organized  disease-pro- 
ducers of  the  fundamental  disturbance — in  the  mucosa  of  the  stom- 
ach, or  even  by  the  toxic  metabolic  products  of  these  microbes. 
In  addition  to  the  infectious  diseases  already  mentioned,  this  sym- 
pathetic form  may  be  a  consequence  of  diseases  of  the  heart,  lungs, 
kidneys,  and  liver,  causing  venous,  passive  congestion  of  the  gastric 
mucosa  (Stauungskatarrh).  In  cardiac  and  nephritic  diseases  the 
passive  gastric  congestion  may  be  relieved  by  appropriate  medica- 
tion directed  to  the  fundamental  disorder;  /.  e.,  the  use  of  digitalis, 
strychnin,  and  diuretics. 

Pathological  Histology. — According  to  Orth  ("  Speciellepatho- 


398  ACUTE    GASTRITIS. 

log.  Anatomic,"  Bd.  i,  S.  702),  our  knowledge  concerning  the 
pathological  histology  of  the  exudative  inflammation  of  the  stomach 
is  very  limited  ;  in  the  first  place,  because  uncomplicated,  simple 
acute  gastritis  rarely  ends  in  death,  and,  secondly,  because  post- 
mortem changes  and  autodigestion  exert  a  most  disturbing  and 
disfiguring  effect,  particularly  in  these  superficial  diseases.  In  a 
case  which  M.  Laboulbene  observed — twenty-four  hours  after  death 
by  rupture  of  an  aneurysm — there  existed  hyperemia  of  the  mucosa, 
localized  ecchymoses,  swelling  of  the  mucous  alveoli,  and  augmen- 
tation of  the  mucus. 

Delafield  and  Prudden  give  essentially  these  same  changes 
("  Text-book  on  Pathology  "),  also  Ziegler  ("  Lehrbuch  d.  allg.  und 
spec,  pathol.  Anat.,"  Jena,  1890),  which  may  be  summarized  as 
follows  :  The  surface  of  the  mucosa  is  covered  by  a  tough,  glassy, 
cloudy,  or  reddish  mucus.  The  mucosa  itself  is  injected,  swollen, 
and  characterized  by  a  hyperemia,  which  is  limited  generally  to 
the  pyloric  region,  and  rarely  extends  to  the  entire  mucosa.  Red 
spots,  either  well  circumscribed  or  diffuse,  are  very  evident,  and 
ecchymoses  are  scattered  throughout  the  mucous  membrane. 
Larger  suggillations  occur  also,  but  are  rare. 

The  histological  changes  are,  by  most  German  authors,  said  to  be 
out  of  proportion  to  the  degree  and  intensity  of  the  symptoms 
(Fleiner,  loc.  cit.,  p.  233):  That  is  to  say,  they  expect  a  greater 
extension  and  degree  of  inflammation  to  correspond  to  the  severity 
of  the  symptoms,  and  are  surprised  not  to  find  it.  Fischl  asserts 
this  particularly  of  the  gastro-enteritis  of  children  (Fleiner,  loc.  ciL, 
p.  233).  However,  the  exact  and  very  instructive  investigations  of 
William  D.  Booker  ("Johns  Hopkins  Hospital  Reports,"  vol.  vi, 
pp.  159-258,  plates  xvi  to  xxi)  show  quite  the  contrary.  Booker's 
researches  demonstrate  destruction  of  the  superficial  epithelium  in 
parts  and  infiltration  of  the  mucosa  with  polynuclear  leukocytes. 
Many  oxyntic  cells  are  without  nuclei,  and  show  only  loose, 
granular  protoplasm  remaining.  Epithelial  cells  and  fragments  of 
glands  are  collected  in  heaps  on  the  surface,  but  not  to  so  marked 
an  extent  as  in  the  intestine  (Booker,  loc.  cit.,  p.  251).  In  a  i&w 
cases  of  acute  gastritis  associated  with  enteritis  he  found  the 
entire  gastric  mucosa  destroyed.  Bacteriological  cultures  were 
made  in  23  cases  ;  in  19  the  colonies  were  very  numerous,  in  two 
moderately  numerous,  and  in  two  there  were  no  colonies  of  bac- 


BACTERIOLOGY    OF    GASTRITIS. 


399 


teria,  but  many  of  o'idium  albicans.     Tabulated,  his  results  appear 
as  follows : 


Predom- 
inant. 

Numerous. 

Few. 

Absent. 

Pure 
Culture. 

Cases. 

Cases. 

Cases. 

Cases. 

Cases. 

Oidium  albicans, 

3 

3 

I 

14 

o 

Bacillus  coli  communis,     .    .    . 

5 

8 

4 

6 

o 

Bacillus  lactis  aerogenes,  . 

7 

2 

5 

7 

2 

Proteus  vulgaris, 

3 

O 

2 

i8 

O 

Streptococci, 

o 

4 

3 

i6 

O 

Booker,  like  A.  Czerny  and  P.  Moser,  concludes  that  the  gastro- 
enteritis of  children  is  a  general  infectious  disease,  with  auto- 
intoxication, in  which  other  organs  of  the  body  participate,  either 
as  a  result  of  an  invasion  of  the  body  by  bacteria,  as  is  often  the  case 
with  the  lungs,  or  from  the  effects  of  poisons  absorbed  from  the 
gastro-intestinal  canal.  This  infantile  digestive  affection  is  un- 
doubtedly a  more  severe  and  acute  disease  than  any  gastritis  that 
occurs  in  adults,  but  its  study  certainly  aids  our  knowledge  of  the 
allied  pathological  states  of  adults.  There  are  a  number  of  inflam- 
mations, occurring  in  adults  as  well  as  children,  that  are  followed  or 
preceded  by  digestive  disorders,  the  etiology  of  which  is  much 
cleared  up  by  the  work  of  the  authors  above  mentioned.  We  refer 
to  the  obscure  attacks  of  parotitis,  tonsillitis,  and  pharyngeal  abscess 
sometimes  following  well-defined  gastric  ulcer,  and  to  the  disorders 
of  the  heart  and  nervous  system  concomitant  or  succeeding  gastro- 
intestinal lesions. 

These  secondary  attacks  at  times  may  be  auto-intoxications ; 
then,  again,  they  show  the  unmistakable  signs  of  direct  infection 
secondary  to  digestive  trouble,  for  in  the  superficial  epithelium  is 
to  be  found  the  chief  protection  of  the  mucosa  against  the  invasion 
of  bacteria.  When  the  epithelium  is  well  preserved,  bacteria  are 
not  found  in  the  mucosa  beneath,  whereas  they  may  be  seen 
entering  it  where  the  epithelium  has  been  lost  or  injured  (Booker, 
loc.  cit.).  The  first  step  in  the  pathological  process  is  probably  an 
injury  to  the  epithelium  from  abnormal  or  excessive  fermentation 
in  the  stomach,  or  from  toxic  products  of  bacteria  and  the  many 
other  conditions  that  have  already  been  described.  (See  Plate  VI.) 
To  prevent  the  effects  of  autodigestion  and  postmortem  digestion 
on  the  gastric  mucosa,  Ewald  suggested  washing  out  the  stomach 
immediately  after  death  and  filling  it  with  alcohol.     This  may  in 


400  ACUTE    GASTRITIS. 

future  save  a  large  number  of  futile  investigations.  Formerly  one 
depended  largely  on  the  studies  of  gastritis  experimentally  pro- 
duced in  animals  for  recognition  of  the  pathological  changes.  Thus, 
Ebstein  produced  gastritis  by  injecting  absolute  alcohol  into  the 
stomachs  of  dogs. 

Ewald  and  Ebstein  describe  a  granular,  cloudy  swelling  in  the 
superficial  epithelium.  While  there  is  no  differentiation  possible 
between  the  parietal  or  oxyntic  and  the  central,  chief,  or  ferment 
cells,  both  varieties  are  either  swollen  •  or  contracted,  granular, 
cloudy,  and  with  very  indistinct  nuclei.  Between  the  different  epi- 
thelia  and  in  the  interglandular  connective  tissue  there  are  consid- 
erable masses  of  round  cells.  In  these,  as  well  as  in  the  emigrated 
leukocytes  and  the  cylindrical,  superficial  cells,  numerous  karyoki- 
nectic  figures  are  very  evident,  and  were  claimed  by  Sachs  {loc. 
cit.)  to  be  characteristic  of  acute  gastritis,  but  this  is  denied  by 
Ewald. 

Beaumont  [loc.  cit?)  gives  some  strikingly  correct  descriptions  of 
the  conditions  observed  in  the  stomach  of  his  patient,  Alexis  St. 
Martin,  when  it  was  acutely  inflamed  in  consequence  of  overfeeding 
or  of  abuse  of  alcoholic  beverages.  He  states  that  the  mucosa 
was  mostly  very  hyperemic,  even  when  no  digestion  was  going  on, 
swollen,  and  covered  with  a  thick  layer  of  tough  mucus.  After 
ingestion  the  food  was  not  digested,  but  remained  in  the  stomach 
from  four  to  six  hours.  The  secretion,  which  was  much  diminished, 
was  only  rarely  faintly  acid,  mostly  it  was  found  alkaline  or  neutral. 
After  a  few  days  the  mucus  became  still  thicker,  but  the  hyperemia 
grew  less.  This  and  the  following  account  of  Beaumont  on  the 
state  of  the  mucosa  in  gastritis — "  its  surface  was  marked  with 
numerous  white  spots  and  vesicles  like  coagulated  lymph,  between 
which  were  very  dark  red  spots  " — is  considered  by  Fleiner  (p.  232, 
loc.  cit)  and  Fleischer  (p.  802,  loc.  cit.)  as  unintelligible  in  the  light 
of  our  present  knowledge.  These  remarks  of  the  American  pioneer 
of  gastric  pathology,  considered  in  that  very  light,  impress  us  as 
a  surprisingly  acute  and  exact  description  of  the  mucosa  in  certain 
types  of  gastritis,  and  inspire  the  latter-day  student  with  respect  for 
the  powers  of  observation  in  the  man.  Fisch  ("  Fleiner's  Lehrbuch," 
p.  233),  after  what  he  considers  very  detailed  and  careful  investiga- 
tions, differentiates  three  forms  of  gastritis  in  children  :  (i)  An 
interstital  gastritis,  which  he  supposes  to  start  from  the  connective 
tissue  ;  (2)  a  parenchymatous   inflammation  having  its  seat  in  the 


SYMPTOMS    AND    COURSE.  4OI 

glandular  tubes  ;  and  (3)  a  combined  parenchymatous  interstitial 
inflammation.  The  interstitial  affection  may  be  interglandular  or 
submucous. 

Symptomatology  and  Course. — Immediately  after  gross  in- 
sults to  the  gastric  physiology,  characteristic  signs  and  symptoms 
appear.  These  are  fullness  in  the  epigastrium,  which  is  distended 
and  painful  on  pressure.  Eructation,  which  at  first  may  bring  relief, 
later  on  increases  so  as  to  be  a  great  annoyance.  Thirst,  anorexia, 
and  even  disgust  for  food,  may  accompany  this.  The  tongue  is 
often  thickly  covered  with  a  tenacious  white  fur,  retaining  the  im- 
pressions of  the  teeth,  and  colored  by  food  or  drugs;  the  breath  is 
offensive.  The  secretion  of  saliva  is  augmented,  the  pulse  small 
and  rapid.  There  may  be  painful  contractions  of  the  esophageal 
musculature,  spasmodic  yawning,  and  herpes  labiales.  A  burning 
pain  in  the  epigastrium,  which  may  radiate  to  the  hypochondriac 
regions,  arises  under  the  sternum  (pyrosis)  toward  the  throat,  caus- 
ing burning  all  the  way,  and  sometimes  raising  sour  or  bitter 
stomach  contents.  As  water  and  other  liquids  diminish  the  gastric 
burning,  the  patients  usually  show  great  thirst.  The  appetite,  how- 
ever, is  absent,  or  there  is  a  perverse  craving  for  piquant,  acid,  or 
salty  foods,  while  the  habitual  diet  is  detested.  Taste  is  much  dis- 
turbed. The  nervous  symptoms  are  general  malaise,  indisposition 
to  mental  or  bodily  work,  prostration,  cerebral  pressure,  and 
frontal  headache.  Palpitation  of  the  heart,  giddiness,  and  a  feeling 
of  fear,  with  profuse  sweating,  are  sometimes  present.  Nervous  and 
less  resistant  patients  (children)  may  have  delirium.  Fleiner  de- 
clares that  general  convulsions  or  loss  of  consciousness  are  not 
rare  in  his  experience. 

All  these  symptoms  may  arise  directly  from  the  stomach  or 
reflexly  from  the  central  nervous  system,  which  in  these  cases 
suffers  intensely  at  times  through  the  absorption  of  toxins  from  the 
stomach.  If  the  nausea  increases  to  emesis,  there  will  be  at  first 
vomiting  of  food  that  has  been  eaten  many  hours  before.  This 
vomited  material  is  mostly  badly  digested,  and  imbedded  in  mucus. 
After  emesis  the  symptoms  may  ameliorate,  and  the  nausea  cease  ; 
very  frequently,  however,  the  vomiting  continues  when  no  more 
food  is  in  the  stomach.  Then  saliva,  mucus,  bile,  and  even  blood, 
may  be  forced  up  under  great  retching  and  suffering.  Intestinal 
parasites  have  in  this  way  been  forced  into  the  stomach  and  vomited 
up.     Skoda  first  directed  attention  to  cases  in  which  vomiting  was 


402  ACUTE    GASTRITIS. 

much  impeded  (at  times  prevented)   by  spasm   of  the   sphincters, 
particularly  at  the  cardia. 

If  the  last  meals  contained  an  abundance  of  carbohydrates  or 
fats,  the  vomited  material  will,  on  testing,  show  an  abundance  of 
lactic,  butyric,  and  fatty  acids  ;  it  will  also  contain  acetic  acid  from 
the  alcohol  which  was  either  the  cause  of  all  the  difficulty  or 
which,  in  nine  cases  out  of  ten,  has  been  administered  by  laymen. 
But  the  most  characteristic  chemical  condition  is  the  entire  absence 
of  free  hydrochloric  acid  in  the  vomited  matter,  which  is  the  cause 
of  the  perverse  fermentations  and  decomposition  in  the  gastric 
contents. 

The  occurrence  of  sulphuretted  hydrogen  in  the  contents  of  the 
stomach  and  in  the  urine,  which  has  been  reported  by  Senator, 
indicates  a  degree  of  albuminoid  decomposition  which  is  ex- 
tremely rare. 

State  of  tlie  Urine. — The  quantity  is,  as  a  rule,  diminished;  in 
febrile  cases  the  specific  gravity  is  high,  and,  when  constipation  is 
present,  it  contains  an  excess  of  indican. 

Fever. — While  about  one-half  of  the  cases  transpire  without  rise 
of  temperature,  in  the  other  half  fever  is  present,  appearing  sud- 
denly, and  reaching  at  times  105°  F.  (40°  C).  This  form  may,  in 
the  beginning,  occasion  some  difficulty  in  the  diagnosis,  because  of 
its  strong  resemblance  to  developing  enteric  (typhoid)  fever.  Under 
these  circumstances  Widal's  method  of  ascertaining  typhoid  fever, 
by  the  effect  of  the  serum  of  such  patients  on  the  typhoid  bacillus, 
is  worth  trying  for  diagnostic  differentiation  [Le  Bulletin  Medical, 
1896,  Nos.  59, 61,64,78,  83  ;  1897,  No.  4).  AlsoC.  Frankel  {Dentsch. 
med.  Wochenschr.,  1897,  No.  3)  and  Wyatt  Johnson  [N.  Y.  Med.  Jour., 
Oct.,  1896,  and  Med.  News,  Jan.,  1897).  Some  German  writers 
still  speak  of  gastric  fever  as  an  infectious  disease  peculiar  to  itself. 
(See  F.  Schmidt,  "  Dissertation,"  Berlin,  1885  ;  "  Z.  Frage  d.  Exi- 
stenz  d.  gastrisch.  Fiebers,  als  einer  eigenartigen  Krankheit") 

Though  it  is  difficult  to  furnish  proof  of  a  direct  infection  in  these 
febrile  forms  at  present,  it  is  not  at  all  impossible  that  such  a  gas- 
tritis may  exist.  Future  bacteriological  studies  in  this  disease  may 
throw  much  light  on  this  point.  The  fever  of  acute  gastritis  is 
usually  preceded  by  repeated  chilly  sensations  or  by  a  typical 
shaking  chill. 

Duration. — If  the  rules  of  hygiene  are  regarded  and  the  patient 
observes  a  careful  diet,  the  disturbances  will  disappear  entirely  in 


DIFFERENTIAL    DIAGNOSIS.  4O3 

from  three  to  four  days  ;  there  are,  of  course,  much  shorter  attacks. 
The  stomach  remains  very  sensitive  to  errors  of  diet,  etc.,  for  a 
varying  time.  A  number  of  neglected  cases,  or  those  occurring  in 
very  weakened  individuals,  may,  by  a  gradual  transition,  turn  to 
the  subacute  or  chronic  form. 

Diagnosis. — In  cases  that  are  not  accompanied  by  any  fever 
there  should  be  no  difficulty  in  determining  the  nature  of  the  dis- 
ease, especially  as  the  direct  cause  is,  in  most  instances,  apparent. 
The  febrile  form  may  be  confounded  with  beginning  enteric  fever; 
during  the  first  three  days  of  the  attack  it  may  be  impossible  to 
differentiate  the  two,  Widal's  method  giving  a  negative  result  if 
instituted  before  the  second  week  of  typhoid  fever.  The  existence 
of  fever  blisters  (herpes  labialis),  which,  according  to  Leo  {loc.  cit., 
p.  66),  speaks  against  typhoid,  is,  in  our  experience,  an  unreliable 
sign  ;  the  results  of  the  blood  examinations  are  contradictory,  and  in 
the  urine  no  diagnostic  feature  is  known.  The  diazo-reaction  of 
Ehrlich,  even  when  performed  in  the  originator's  latest  method 
{^Charite  Armalen,  1886,  Bd.  11),  has,  in  our  experience,  been  of  no 
diagnostic  value.  In  this  respect  we  can  confirm  the  opinions  of 
von  Jaksch  and  Eichhorst  ("  Klinische  Untersuchungsmethoden," 
p.  JT]^.  Most  infectious  diseases  (see  above)  are  in  the  beginning 
accompanied  by  an  acute  gastritis;  in  most  of  them,  particularly 
the  exanthemata,  a  differentiation  is  not  difficult.  It  is  good 
advice  that  von  Leube  ("  Specielle  Diagnose,"  i  Theil,  Leipzig) 
gives  when  he  says :  "  In  all  cases  with  high  fever  think  of  other 
sources  and  causes  before  settling  upon  gastritis."  There  are  two 
conditions  which,  as  far  as  can  be  judged  at  present,  are  reliable 
factors  in  the  early  diagnosis  between  acute  gastritis  and  enteric 
fever.  (The  early  diagnosis  is  the  only  one  we  are  here  discussing  ; 
the  element  of  time  is  very  important  here,  as  simple  gastritis  is 
only  of  three  days'  duration.)  The  differentiating  factors  are  the 
manner  and  rise  of  the  fever  and  the  state  of  the  spleen. 

In  enteric  fever  we  mostly  meet  with  a  gradual  rise  of  tempera- 
ture and  a  gradual  fall  when  the  fever  subsides.  In  gastritis  the 
temperature  rises  abruptly,  the  remissions  are  slighter,  and  the  fall 
is  more  sudden.     (See  Osier,  "  Principles  and  Practice  of  Medicine," 

P-  349-) 

Therefore  frequent,  regular,  thermometrical  studies  are  not  to  be 
omitted.  The  second  diagnostic  sign  of  value  is  the  presence  or 
absence   of  splenic  tumor ;    its  presence  points   to   enteric   fever. 


404  ACUTE    GASTRITIS. 

Unfortunately,  the  splenic  enlargement  is  not  invariably  present  in 
enteric  fever  at  the  outset.  * 

Prognosis. — Speaking  generally,  the  prognosis  of  simple  acute 
gastritis,  except  in  very  old  patients  and  in  young  children,  is 
favorable. 

Treatment. —  i.  Prophylactic.     2.  Dietetic.     3.  Medicinal. 

Prophylactic  treatment  will  especially  be  applicable  to  cases  that 
are  known  to  have  enfeebled  digestive  organs  or  in  which  attacks 
of  digestive  disease  have  repeatedly  occurred.  Attention  must  be 
directed  to  avoidance  of  injurious  influences  that  may  affect  the 
stomach  directly  from  external  causes  and  those  that  affect  it  from 
internal  causes. 

{a)  The  external  causes  are,  of  course,  the  manifold  varieties  of 
trauma  that  are  possible  in  modern  life;  not  only  those  that  can 
occur  accidentally,  but  those  that  occur  gradually  by  pressure  upon 
the  abdomen  from  without,  such  as  is  requisite  in  the  execution  of 
certain  trades,  the  manipulation  and  handling  of  machines,  and  even 
the  continuous  pressure  of  tables. 

A  very  important  matter  in  this  respect  is  clothing,  particularly 
that  of  the  female  sex.  Female  clothing  of  to-day,  as  far  as  the 
maintenance  of  healthy  digestive  organs  is  concerned,  is  not  at  all 
conformable  to  this  object.  The  much-condemned  corset  is  not 
even  the  worst  part  of  the  female  outfit,  for  a  properly  constructed 
and  correctly  applied  corset  need  not  necessarily  effect  damage ; 
but  for  the  greater  number  of  ladies  wearing  them  it  would  be  more 
hygienic  to  discard  it  altogether,  and  preserve  form  and  insure 
support  to  the  breast  and  graceful  carriage  in  the  style  of  the  ancient 
Greeks,  i.  e.,  by  broad,  soft  bandages  applied  immediately  to  the 
skin,  over  the  underwear,  or  even  externally  (Julia  Marlowe  style). 
A  more  harmful  thing  than  the  corset  is  the  tying  of  the  skirts  and 
dresses  around  the  waist. 

The  most  judicious  female  clothing,  conformable  to  the  object  of 
relieving  the  abdominal  organs  of  pressure,  would  be  represented 
by  garments  made  in  one  piece,  of  which  the  upper  part  supports 


*Dr.  Edward  L.  Whitney  and  myself  have  observed  that  the  Widal  test  for  typhoid 
fever  failed  when  instituted  during  the  first  week.  Apparently,  a  certain  time  is  required 
before  the  serum  acquires  the  characteristic  effect  on  the  typhoid  bacilli.  This,  of  course, 
— if  confirmed  by  further  observations, — would  render  it  useless  in  the  differential  diag- 
nosis between  typhoid  fever  and  acute  gastritis. 


ADULTERATIONS    AS    CAUSE    OF    GASTRITIS.  4O5 

the  lower  from  the  shoulders.     (Kleinwachter,  D.  vied.  Zeit.,  1894, 
S.  82;  also  Meinert,  Volhnann' s  klin .  Vortrdge,  115,  116.) 

The  abdomen  should  always  be  kept  warm,  not  by  special  ban- 
dages, but  by  garments  that  are  made  of  wool,  fitting  quite  com- 
fortably to  the  skin,  and  closed  below.  All  digestive  sufferers 
should  take  special  care  against  cooling  or  sudden  chilling  of  the 
surface. 

{b)  The  internal  causes  or  injurious  influence  must  chiefly  be 
avoided  in  the  food.  Exclusive  of  corrosive  and  irritant  poisons 
that  may  be  swallowed  accidentally,  the  food  articles  may  contain 
adulterations  in  the  form  of  organic  or  inorganic  additions  that  are 
incompatible  with  sound  digestion,  or  the  food  ma}-  be  decayed, 
fermenting,  or  decomposed.  Among  the  adulterations  might  be 
mentioned  that  of — 

Milk,  with  water,  sodium  carbonate  and  bicarbonate,  borax,  and 
salicylic  acid ;  or  it  may  contain  bacteria  (tubercle  and  t\-phoid 
bacilli). 

Cheese,  adulterated  with  decomposable  gelatins,  and  may  con- 
tain lead  and  tin  from  the  packing,  and  also  mineral  impurities. 

Sausages  may  contain  flour,  fuchsin  (for  coloring),  organic  poi- 
sons, bacteria,  ptomaines.     (Botulismus  :  poisoning  by  sausage.) 

Butter  may  be  adulterated  b\-  mineral  substances,  gypsum,  lime, 
coloring  matters,  lead  chromate,  cresol,  dinitronaphthol,  and  the 
caustic  alkalies. 

Vegetable  Food. — Flour  has  been  found  adulterated  b}-  sand, 
g\'psum,  and  alum,  and  also  mixed  with  the  fungi  of  rye  or  wheat ; 
ergot  poisoning  by  rye  flour  has  been  observed  in  Russia.  Some 
confectioners  use  dye-stuffs  of  various  kinds,  all  of  which  are  dan- 
gerous. Coffee  is  sometimes  adulterated  with  copper  or  lead  salts 
to  give  it  the  desired  color.  Wine,  beer,  and  whisky  are  subject  to 
numerous  adulterations  to  effect  cheaper  manufacture,  to  preserve 
or  color,  or  to  give  any  desired  taste.  In  beer,  picric  acid,  colchicum, 
and  strychnin  have  been  found  as  substitutes  for  hops  ;  impure 
grape  sugar  for  malt;  alkalies  to  prevent  souring,  and  salicylic  acid 
to  preserve  it  or  check  fermentation. 

Furthermore,  the  prophylaxis  must  be  directed  to  the  ii)  quality, 
(2)  quantity  of  the  food,  (3)  the  proper  preparation  of  the  food  by 
chewing  and  insalivation,  and  proper  conduct  after  eating. 


406  ACUTE    GASTRITIS. 

These  subjects  are  best  studied  in  the  section  on  dietetics  (p.  177 
to  284).* 

Dietetic  Tj-eatment. — Acute  inflammation  of  any  structure  is 
best  treated  by  rest,  and  the  stomach  forms  no  exception. 
Hence,  total  abstinence  from  food  and  great  reduction  of  the 
quantity  of  fluid  imbibed  is  often  curative  after  an  interv-al  of 
thirty-six  hours.  So,  for  the  first  two  days  as  Httle  food  as  possible 
should  be  allowed.  To  accomplish  this  very  simple  and  logical 
object  is,  in  private  practice,  a  most  difficult  thing.  There  is  an 
incorrigible  custom  among  relatives  of  stuffing  the  patient  with  all 
manner  of  articles,  which  it  is  hard  to  combat.  At  the  bottom  of  all 
this  probably  lies  the  popular  superstition  that  a  human  being  can 
not  exist  twelve  hours  without  food.  A  total  abstinence  from  food 
is  borne  very  well,  and  leads  most  rapidly  to  recovery.  For  the 
intolerable  thirst,  cracked  ice  should  be  given,  a  wineglassful  in 
two  hours.  If  there  are  signs  of  collapse,  champagne  or  brandy 
can  be  added  with  safety,  even  if  alcohol  was  the  cause  of  the 
trouble. 

After  the  twenty-four  hours  of  total  abstinence,  the  first  food  to 
be  given  is  milk,  or  beef  bouillon,  with  soft  rice  or  an  &^^  beaten  up 
in  it.  A  good  stimulating  food,  when  there  are  signs  of  prostration, 
consists  of  one  raw  &g^  beaten  up  with  ^2  of  a  pint  of  Hocheimer, 
or  a  full  pint  if  desired,  and  sweetened  to  taste,  with  a  slight  flavor 
of  lemon  added.  The  wine  may  have  to  be  diluted  if  the  gastric 
mucosa  is  very  sensitive.  Of  the  above,  a  small  wineglassful 
(two  ounces)  may  be  given  every  two  hours  (quite  warm,  if  pre- 
ferred). On  the  third  day  a  few  soda  crackers  or  cakes  may  be 
allowed.  On  the  fourth  day  a  gradual  return  to  more  reconstruc- 
tive food  is  advisable,  such  as  calf's  brain,  free  from  all  stringy 
and  membranous  parts,  boiled  first  in  bouillon,  then  rapidly  broiled ; 
sweetbread  or  thymus  gland  broiled;  breast  meat  of  broiled  squab, 
pigeon,  or  chicken.  Finally,  on  the  sixth  day  after  the  attack, 
finely   scraped    broiled    beef,    potato    puree,    stewed    apples,    rice, 


*Gilman  Thompson,  "  Dietetics.'" 

AVegele,  "  Dietetische  und  medicamentose  Behandlung   der   Mageniind  Darmkrank- 
heiten." 

Penzoldt,  "  Handbuch  der  speciellen  Therapie  innerer  Krankheiten,"  volume  iv. 
Biedert  u.  Langermann,  "  Diatetik  u.  Kochbuch,"'  Stuttgart,  1895. 
J.  Bumey  Yeo,  "  Food  in  Health  and  Disease,''  Philadelphia,  1897. 
Sir  William  Roberts,  "Digestion,"'  etc. 


MEDICINAL   TREATMENT.  40/ 

tapioca,  very  soft  omelette.  A  plan  that  is  generally  successful  is 
to  follow  out  the  Penzoldt  diet  order  given  on  p.  219. 

Medicinal  Treatment. — Acute  gastritis  must  be  treated  without 
drugs  wherever  it  is  at  all  possible.  If  the  dietetic  rules  of  total 
abstinence  from  all  food  for  twenty-four  hours  and  cautious  return 
to  light  diet  are  carried  out,  two-thirds  of  the  cases  will  recover 
without  medicines.  Not  a  few  patients,  even  children,  will  do  this 
instinctively,  and  not  permit  any  cramming  with  food  until  the 
stomach  has  become  rested  and  a  natural  desire  therefor  returns. 
The  most  important  indication  of  treatment  is  usually  done  by  the 
injured  organ  itself,  i.  e.,  evacuation. 

If  emesis  does  not  occur  easily  at  the  outset,  both  Ewald  and 
Boas  recommend  the  following  emetic  : 

K.     Pulvis  ipecacuanhas,      1.5       grs.  xxiij 

Antimonii  et  potassi.  tartratis, 0.05     gr.  |.  M. 

SiG. — Fiat  chart  No.  I.      To  be  taken  at  once  or  in  divided  doses. 

In  children,  Ewald  favors  a  teaspoonful  of  the  syrup  of  ipecac. 
We  have  so  far  been  able  to  accomplish  all  that  was  necessary  with- 
out emetics,  and  are  loath  to  advise  their  use.  Where  emesis  must 
be  brought  about  it  is  more  expedient  and  reliable  to  use  ^^  of  a  gr. 
of  apomorphin  hypodermically.  Another  drug  which  gives  satis- 
faction to  both  patient  and  physician  in  these  attacks,  particularly 
when  there  is  constipation,  is  calomel.  Sometimes,  when  persistent 
nausea  follows  thorough  emesis,  it  may  even  act  as  agastric  sedative. 
Ewald  advises  six  grs.,  repeated  in  an  hour.  While  this  dose  seems 
large,  it  is  by  no  means  too  large,  and  will  produce  a  cholagogue 
and  sterilizing  effect  that  may  terminate  the  gastritis  then  and  there. 
Formerly  we  used  tablet  triturates  of  j^  of  a  gr.  of  calomel  every 
hour  until  purgation  ;  they  are  more  pleasant  to  administer.  The 
larger  dose  recommended  by  Ewald  produces  more  of  an  antiseptic 
action,  since  a  portion  of  it  is  converted  into  mercuric  chlorid. 

Calomel  can  not  be  given  at  the  beginning  of  the  gastritis  very 
well ;  the  second  day  is  best  suited  for  its  administration.  Although 
we  mention  these  drugs,  it  is  not  with  a  view  to  routine  treatment, 
but  to  aid  in  meeting  special  indications.  When  pain  in  the  stomach 
is  attended  by  chilliness,  we  advise  hot  poultices  over  the  entire 
abdomen,  turpentine  stupes,  or  spongiopilin  dipped  in  hot  water 
and  10  to  20  drops  of  tincture  of  opium  sprinkled  over  before  it  is 
applied  to  the  epigastrium.  But  when  there  is  gastric  pressure  that 
seems   to  embarrass  respiration,  associated  with  explosive  eructa- 


408  ACUTE    GASTRITIS. 

tion,  cold  hydropathic  appHcations  are  more  effective  than  hot  ones. 
When  there  is  fever  these  applications  should  be  made  with  ice- water 
or  the  ice-bag.  Intense  pain  is  met  with  hypodermic  injections  of 
morphin  ^^  of  a  gr.,  and  atropin  sulphate  ^to  of  a  gr.  The  follow- 
ing suppositories  of  Boas  may  be  applied. 

R.     Codein  phosphoric, 0.05  grs.  v 

Ext.  belladonnje, 0.03         grs.  ij. 

F.  c.  butyr.  cacao  suppositor  No.  X. 
SiG. — One  everj"  hour  until  relieved.     Where  the  pain  must  be  relieved,  and  the 
hypodermic    injection  is   not  permitted  and  medication  per  os  not  retained,    they   are 
very  useful. 

By  the  mouth,  codein  is  best  given  in  the  following  manner: 

li .      Codein  phosph., 0.4         gr.  vj 

Aqua  menth.  pip., 40.0       f^iss.  M. 

SiG. — One  teaspoonful  every  three  hours. 

If  symptoms  of  hyperacidity,  keeping  up  the  annoying  pyrosis 
and  thirst,  are  predominant,  it  may  be  impossible  to  avoid  alkalies. 
They  are  expediently  prescribed  in  the  succeeding  formula: 

R .     Magnesia,  calcined, 

Sodium  bicarbonate, aa  .    .    .    .  10. o      ^ijss 

Menthol, 2.0      grs.  xxx. 

Mix  thoroughly. 

SiG. — One-half  teaspoonful  pro  re  nata  followed  by  ^  iii  water. 

It  is  not  rational  to  give  purgatives,  because  they  irritate  the 
inflamed  mucosa ;  calomel  is  the  only  drug  of  this  nature  that  can 
safely  be  given,  but  not  before  the  fermenting  stomach  contents 
have  been  removed  by  emesis  or  lavage.  To  effect  purgation  be- 
fore the  stomach  is  emptied  exposes  the  intestine  to  infection  from 
the  septic  mass  forced  through  it.  Persistent  vomiting  may  call 
for  especial  treatment;  here,  morphin  hypodermically,  mustard 
plasters  to  the  epigastrium,  and  small  pieces  of  ice  will  be  suffi- 
cient. A  singular  case  of  very  exhausting  and  persistent  vomiting 
was  in  our  practice  relieved  by  bismuth  salicylatis  gr.  x,  cocain 
hydrochlorate,  gr.  )4  ;  menthol,  gr.  ii  ;  aquae  camphor,  f.^ss.  M. 
Every  two  hours  until  relieved.  Vomiting  of  this  character  is  bound 
to  bring  on  collapse.  It  is,  fortunately,  a  rare  complication,  but 
must  be  met  energetically  if  it  develops.  In  concluding  the  medici- 
nal treatment,  we  desire  to  refer  to  a  successful  therapeutic  measure 
which  does  not  properly  belong  under  this  heading,  because  it  is 
not  medicinal  but  mechanical. 


LAVAGE  OF  STOMACH  AND  COLON  FOR  ACUTE  GASTRITIS.  4O9 

This  consists  of  evacuating  the  stomach  with  the  tube,  and  im- 
mediately thereupon  disinfecting  it  by  washing  it  out  with  a  solution 
of  the  following  composition  : 

R .      Thymol, 0.5  gr.  viij 

Acid,  boracic, 16.  g  ss 

Warm  water, 500.  Oj  (one  pint).  M 

Sig. — Lavage  fluid. 

The  water  during  lavage  must  be  used  quite  warm  and  the  an- 
tiseptic not  used  until  the  plain  water  runs  out  clear.  Catch  up  the 
outflowing  antiseptic  fluid  and  ascertain  that  it  approximates  one 
pint ;  a  few  ounces  retained  will  not  do  harm.  Vomiting,  as  a  rule, 
ceases  entirely  after  this.  Six  hours  later  wash  out  the  colon  by 
large  enemata  of  ten  per  cent,  solution  of  boracic  acid,  no  matter 
whether  the  patient  has  diarrhea  or  constipation.  If  diarrhea 
exist,  it  is  absolutely  rational  to  effect  the  removal  of  the  putrefy- 
ing colonic  contents  by  large  enemata  (given  in  the  knee-chest 
posture),  and  if  constipation  exist,  the  stagnation  of  feces  certainly 
aggravates  the  symptoms  by  increasing  flatulence  and  abdominal 
pressure.  If  there  is  any  therapeutic  measure  in  addition  to  absti- 
nence from  food  that  merits  confidence,  it  is  this  mechanical  cleans- 
ing of  stomach  and  colon.  Rare  cases  of  high  temperature  may 
need  special  therapeutic  measures  for  the  fever.  Here,  also,  drugs 
must  be  avoided  and  the  temperature  reduced  by  sponging  with 
cold  water  or  the  cold  bath. 

In  case  the  appetite  fails  after  the  attack,  or  there  is  protracted 
weakness  with  timidity  and  aversion  to  food,  the  following  tonic 
may  become  useful : 

]^ .      Strychnin,  sulphatis, 0.021  gr.  ^ 

Acidi  hydrochlorici  dilut. , 12.  f  ,^  iij 

Elixir  gentianse  q   s.  ad  mis.,       192.  fS^j-     M. 

SiG. — One   tablespoonful   diluted  with  ^  ij  HjO  three-quarters   of  an  hour  before 
meals,   through  a  glass  tube. 

Forms  of  acute  gastritis  associated  with  copious  vomiting  of  bile 
are  frequently  seen  in  our  latitude  and  termed  "  bilious  attacks." 
There  is  no  liver  disease  associated  with  the  attacks,  and  they  are 
generally  brought  on  by  errors  in  diet  and  mental  strain. 

PHLEGMONOUS     OR   PURULENT    GASTRITIS  — SUPPURATIVE    IN- 
FLAMMATION   OF   THE   STOMACH— GASTRIC   ABSCESS. 

This  is  a  very  acute,  fatal,  and,  fortunately,  very  rare  affection  of 
the  gastric  walls,  apparently  set  up   by  an   invasion  of  pyogenic 

27 


4IO  PHLEGMONOUS    OR    PURULENT    GASTRITIS. 

cocci.  It  is  a  purulent  inflammation  invariably  originating  in  the 
submucous  connective  tissue,  and  from  here  extending  to  the 
mucosa.  Ziegler  ("  Lehrbuch  d.  allgem.  u.  spec.  path.  Anat.." 
1887,  Bd.  II,  S.  516)  describes  large  numbers  of  streptococci  oc- 
curring partly  free  in  the  tissues  and  partly  in  the  protoplasm  of 
the  cells.  In  case  the  serosa  is  invaded,  the  disease,  as  a  rule, 
produces  a  general  fatal,  peritonitis  by  perforation,  unless  an 
infection  of  the  peritoneum  is  prevented  by  an  agglutination  with 
adjacent  organs.  We  have  seen  but  one  case  of  this  sort ;  it  was 
not  diagnosed,  but  our  associate,  Dr.  Delano  Ames,  discovered  it 
at  the  autopsy.  It  had  followed  ulcus  carcinomatosum  of  the 
pylorus.  The  submucosa  and  muscularis  mucosae  were  pushed  apart 
by  numerous  miliary  abscesses.  (See  Hemmeter  and  Ames, 
A^.  V.  Med.  Record,  Sept.,  1897,  "  A  Case  of  Phlegmonous  Gastritis," 
etc.)  We  submit  an  excellent  drawing  showing  four  small  ab- 
scesses forcing  apart  the  fibers  of  the  muscularis  mucosae.  As 
far  as  one  is  able  to  judge  from  the  literature  on  this  subject,  the 
disease  is  inevitably  fatal,  running  most  always  an  acute,  rarely  a 
subacute,  course.  Ewald  {loc.  cit.,  p.  303)  has  seen  only  one  case, 
and  that  at  the  clinic  of  his  teacher,  Frerichs.  It  occurs  much 
oftener  in  men  than  in  women  ;  of  41  cases,  33  were  men  and  eight 
women.  In  a  report  by  Glax  ("  Die  Magenentziindung,"  Deutsche 
med.  Zeit.,  1884,  No.  3)  it  is  stated  that  but  51  cases  had  been 
observed  up  to  that  time.*  Most  authors  who  have  had  experience 
with  the  disease,  distinguish,  first,  an  idiopathic  primary  purulent 
gastritis,  the  etiology  of  which  is  obscure  ;  and,  secondly,  a  sec- 
ondary, metastatic,  phlegmonous  or  purulent  gastritis,  which  is  an 
accompaniment  or  a  sequence  of  other  infections,  such  as  pyemia, 
puerperal  fever,  anthrax,  typhus,  or  variola.  Anatomically,  one 
may  distinguish  a  diffuse  and  a  circumscribed  purulent  inflamma- 
tion of  the  submucosa ;  the  latter  is  spoken  of  as  stomach  abscess. 
Etiology. — The  direct  cause  of  the  rarer  idiopathic  phlegmon- 
ous gastritis  is  unknown.  The  predisposing  causes  may  be  the 
same  as  stated  under  the  etiology  of  simple  gastritis.  The  direct 
causes,  judging  from  anatomical  specimens,  are  undoubtedly  bac- 
terial invasions  of  the  submucosa,  principally  by  pyogenic  cocci 
that  find  portals  of  entry  through  lesions  in  the  superficial  epithe- 

*We  have  collected  the  entire  literature  on  the  subject  of  phlegmonous  gastritis,  which 
is  appended. 


PLATE  V. 


D 


B 


Phlegmonous  Gastritis  in  the  Sequence  of  Ulcus  Carcinomatosum.    Section 

Showing  the  Lower  Part  of  the  Mucous  Coat  with  the  Ends  of  Some 

OF    the    Gastric    Glands,    the    Muscularis    Mucosa,    and    a 

Small  Portion  of  the  Upper  Part  of  the  Submucosa. 

— [Origmal  observation  from  the  Author'' s  Clinic.') 

Objective,  one-sixth.      Eyepiece,  one  inch.      Stained  with  hematoxylon  and  orange  G. 
Magnification  about  320  diameters. 


In  all  sections  the  small  round-cell  infiltration  is  well  marked,  the  cells  chiefly  filling 
up  the  muscularis  mucosas  and  invading  the  lower  portion  of  the  mucous  coat.  In  the 
muscularis  mucosae  these  cells  are  aggregated  into  a  number  of  small,  circular,  dense 
masses  (j9),  miliary  abscesses,  between  which  they  are  but  little  less  numerous.  The 
fibers  of  the  muscularis  mucosas  have  been  widely  sepa.rated  by  these  cells.  Few  cancer 
cells  are  to  be  seen  in  this  portion  of  the  tissue,  but  in  one  place  (C)  they  are  found  plug- 
ging completely  a  small  vessel.  In  the  upper  part  of  the  submucosa  a  few  of  the  cancer 
cells  can  also  be  seen  {D). 


ITS    PATHOllOGICAL    HISTOLOGY.  4I  I 

Hum  of  the  stomach,  such  as  occur  in  most  gastric  diseases,  espe- 
cially in  so-called  exfoliation  in  carcinomata  and  old  ulcers,  or  after 
trauma  caused  by  fish  bones,  seeds,  foreign  bodies,  etc.  Ziegler's 
{loc.  at.)  studies  have  already  been  mentioned.  The  secondary, 
metastatic  phlegmonous  gastritis,  which  seems  most  frequent,  is  that 
following  puerperal  fever,  and  owes  its  origin  to  localization  in  the 
stomach  of  the  specific  organisms  producing  the  fundamental  disease. 
Whatever  they  may  be,  it  is  self-evident  that  only  an  enfeebled 
organ  is  liable  to  such  an  inflammation,  since  pyogenic  cocci  can 
not  resist  the  action  of  the  free  HCl  of  the  gastric  juice. 

Pathological  Anatomy. — The  diffuse  inflammation  rarely  in- 
vades all  parts  of  the  stomach  with  the  same  intensity,  even  if  the 
whole  organ  is  involved.  The  pyloric  portion  is  generally  invaded 
more  than  the  others  ;  toward  the  cardia  the  inflammatory  process 
is  less  and  less  marked,  whilst  the  esophagus  is  rarely  attacked. 
The  submucous  layer  is  most  extensively  altered;  on  cross-section 
it  is  swollen,  showing  an  edematous,  purulent,  or,  at  times,  a  bloody 
infiltration.  From  here  the  inflammation  spreads  along  the  inter- 
glandular  tissue  between  the  glandular  tubules,  effecting  fine  or 
larger  perforations  in  the  mucosa,  which  may  assume  a  sieve-like 
appearance.  Pus  wells  up  through  these  cribriform  perforations  as 
out  of  a  swollen  sponge.  It  may  occur  that  the  mucosa  is  lifted 
from  the  submucosa  by  accumulations  of  pus.  Rokitansky  has 
described  a  case  in  which  the  mucosa  was  only  strikingly  anemic, 
otherwise  unaltered.  Macleod  [Lancet,  1887,  vol.  ii,  p.  1166)  de- 
scribes a  gastric  abscess  in  which  mucosa  was  said  to  be  unaltered. 

Toward  the  deeper  portions  of  the  engorged  layers,  the  process 
spreads  along  the  bundles  of  muscular  fibers  in  the  muscularis, 
which  undergo  fatty  degeneration,  and  show  infiltration  with  pus 
cells  and  proliferation  of  nuclei.  The  serous  or  peritoneal  layer 
may  also  be  lifted  from  the  subserous  or  muscular  layers,  and  per- 
foration, as  a  rule,  rapidly  follows  inflammation  of  this  layer. 
Circumscribed  abscesses,  which  must  be  differentiated  from  the 
diff'use  inflammation,  are  usually  small,  varying  from  the  size  of  a 
hazelnut  to  that  of  a  goose  &gg  (Leube,  he.  cit.).  On  cutting  into 
the  swollen  elevated  areas  of  mucous  membrane,  the  abscess  is 
found  in  the  submucosa,  but  may  extend  through  the  muscularis 
to  the  serosa. 

Symptomatology. — The  symptoms  are  very  much  like  those  of 
a  very  intense  acute  simple  gastritis  ;  the  pain  of  gastric  phlegmon 


412  PHLEGMONOUS    GASTRITIS. 

is  not  materially  increased  by  change  of  position  or  pressure. 
There  is  very  rarely  any  vomiting  of  pus  in  diffuse  purulent  gas- 
tritis. Gastric  abscess  may  be  attended  by  copious  vomiting  of 
pus,  after  which  a  tumor  that  may  have  been  palpable  before  may 
become  much  smaller,  or  disappear  entirely  ;  this  phenomenon 
might  be  significant  for  the  diagnosis  of  gastric  abscess  if  it  were 
not  for  the  fact  that  pus  tumors  of  the  neighboring  organs  some- 
times break  through  into  the  stomach  and  cause  the  same  symp- 
toms. The  fever  reaches  I04°-I05°  F.,  the  patient  being  aware 
from  the  outset  that  he  is  very  seriously  ill.  The  sensorium  is 
much  disturbed  by  great  restlessness,  headache,  insomnia,  delirium. 
To  the  symptoms  of  acute  gastritis  those  of  a  sudden  peritonitis 
may  be  added  at  any  time. 

Diagnosis. — The  important  conditions  for  diagnosis  are  the 
pain,  vomiting,  meteorism,  fever,  diarrheas,  and  general  phenom- 
ena. The  pain  is  localized  in  the  epigastrium  and  said  to  have 
been  absent  in  some  cases.  The  emesis  is  always  present,  and  con- 
sists of  bile,  mucus,  and  food  debris;  in  diffuse  purulent  gastritis, 
pus  has  not  been  noticed  in  the  vomit,  which  strongly  resembles 
so-called  peritoneal  vomiting. 

The  fever  is  very  high,  and  the  temperature  curve  is  said  to 
resemble  those  of  pyemic  fevers,  with  marked  remissions  and 
exacerbations.  Tympanitis  and  diarrhea  are  more  frequent  than 
constipation.  Other  symptoms  are:  rapid  compressible  pulse,  cold 
peripheral  parts,  hurried  respiration,  thirst,  and  a  much-coated 
tongue.  The  course  of  gastric  abscess  is  not  characteristic,  and 
Leube  states  ("  Spec.  Diagnose  d.  inneren  Krankheiten,"  S.  237) 
that  the  diagnosis  is  a  matter  of  chance.  The  attack  may  resemble 
a  circumscribed  peritonitis  or  one  of  the  various  perigastric  inflam- 
mations or  abscesses  ;  according  to  Evvald  {loc.  cit)  it  may  so  mimic 
abscess  of  the  spleen  or  left  lobe  of  the  liver,  that  a  differential 
diagnosis  is  absolutely  impossible.  Deininger  [Detitsches  Arcliiv  f. 
klin.  Med.,  Bd.  xxiii,  S.  268)  held  that  high  fever,  constant  and 
intense  gastralgic  pain  that  is  not  increased  on  movement,  and 
increased  resistance  in  the  epigastrium,  should  be  sufficiently  char- 
acteristic to  justify  a  diagnosis.  These  symptoms,  however,  occur 
also  in  above  conditions  referred  to  by  Evvald.  Chvostek  ( Wiener 
Klinik,  1 88 1,  and  Wiener  ined.  Presse,  1877,  Nos.  22-29),  however, 
seems  to  have  made  the  diagnosis  in  one  of  his  cases.  The  case 
reported  by  the  author  ("  A  Case  of  Phlegmonous  Gastritis,"  etc.. 


INFECTIOUS    GASTRITIS.  4I3 

by  Hemmeter  and  Ames,  Netu  York  Medical  Record  {loc.  cit}), 
was  not  diagnosed.  The  condition  of  diffuse  suppurative  gastric 
inflammation  had  followed  an  ulcus  carcinomatosum,  which  had 
been  recognized  and  successfully  treated  as  a  simple  ulcer  by  Dr. 
E.  L.  Whitney  fourteen  months  before  death  occured.  Where 
there  is  probabilit}^  of  diffuse  or  circumscribed  phlegmonous  gas- 
tritis, the  exploratory  puncture  with  an  aspirating  needle  or  the 
exploratory  incision  is,  in  our  opinion,  justifiable.  In  Penzoldt  u. 
Stintzing's  new  "  Specielle  Therapie  innerer  Krankheiten,"  Volume 
IV,  p.  446,  von  Heinecke  gives  suggestions  for  the  operative  treat- 
ment of  phlegmonous  gastritis. 

Prognosis  is  almost  always  unfavorable,  especially  in  the  diffuse 
form.  After  the  circumscribed  form  and  evacuation  of  the  abscess, 
several  clini-cians  have  reported  recoveries  (Deininger,  ioc.  cit.,  Glax, 
loc.  cit.,  Kirchmann,  loc.  cit.,  also  Buckler,  "  Idiopathic  Phlegmon. 
Gastritis,"  Bayerisch.  Aerztliches  Intelligenzblatt,  1880,  No.  37),  but  it 
is  impossible  to  confirm  whether  they  were  really  gastric  abscesses. 
Dittrich  has  found  cicatrices  in  the  submucosa  pointing  to  the 
possibility  of  healing. 

Treatment. — If  a  diagnosis  could  be  made,  it  seems  to  me  that 
these  cases,  the  diffuse  as  well  as  the  circumscribed  forms,  had 
best  be  treated  surgically.  Under  the  existing  difficulty,  the  treat- 
ment can  be  only  symptomatic  and  limited  to  relieving  pain  by 
hypodermic  injections  of  morphin,  applications  of  ice,  ice  bag  to 
the  stomach,  crushed  ice  by  the  mouth.  To  counteract  collapse, 
wine  enemata  and  hypodermic  injections  of  strychnin  are  recom- 
mended.    Medicines  by  the  mouth  are  worse  than  useless. 

INFECTIOUS  GASTRITIS.  . 
{^Gastritis  infectiosa,  diphtheritica,  cronposa,  mycotica,  parasitaria.) 

As  Penzoldt  correctly  remarks  {loc.  cit?),  every  gastritis  is  to  a 
certain  extent  infectious  ;  for  this  reason  a  number  of  authors 
reject  the  conception  of  infectious  gastritis  as  a  separate  and  dis- 
tinct disease.  Lebert  {loc.  cit?)  and  Oser  (article  on  Gastric  Diseases 
in  "  Eulenburg's  Realencyclopadie,"  second  edition,  volume  xii, 
p.  410)  believe  that  there  is  a  characteristic  infectious  gastritis 
peculiar  to  itself.  Boas  ("  Spec.  Therapie  d.  Magenkrankh.,"  p.  6) 
is  of  the  opinion  that  there  is  a  form  of  acute  gastro-enteritis,  well 
characterized  clinically,  which  differs  from  simple   gastritis  by  the 


414  INFECTIOUS    GASTRITIS. 

gravity  of  the  symptoms,  and  particularly  the  course  of  the  fever, 
so  that  it  merits  separate  consideration.  Ewald,  on  the  other 
hand,  holds  that  there  is  no  sufficient  specificity  of  inflammatory 
processes  affecting  the  stomach  for  establishing  a  separate  class  of 
infectious  gastritis.  Fleiner,  Penzoldt,  and  Einhorn  give  no  sepa- 
rate consideration  to  infectious  gastritis.  Those  that  establish  a 
separate  category  for  this  affection,  class  under  this  head  all  gastric 
invasions  by  infectious  germs,  so  that  all  forms,  as  remarked  before, 
are  to  a  certain  extent  infectious. 

The  symptoms  are  said  to  be  very  similar  to  acute  simple  gas- 
tritis, and  therefore  require  no  further  description.  The  course  is 
more  protracted,  as  it  may  last,  according  to  Boas,  three  to  ten 
days.  According  to  Lebert  {loc.  cit.),  some  cases  may  have  fever  for 
two  to  three  weeks.  In  this  case  the  Widal  method  {loc.  cit?) 
should  be  made  use  of  to  decide  the  nature  of  the  infection. 
Gaffky  {Deittscli.  vied.  Wochenschr.,  1892,  No.  14)  gives  an  account 
of  severe  gastro-enteritis  in  three  persons  who  drank  the  unboiled 
milk  of  a  cow  affected  with  hemorrhagic  enteritis.  Gaff  ky  believes 
that  the  infecting  germ  was  a  particularly  virulent  type  of  the 
bacillus  coli  communis.  A  number  of  similar  mass  epidemics  are 
on  record  (Husemann,  Deutsch.  vied.  Wochenschr.,  1889,  S.  960)  that 
tend  to  strengthen  the  conception  of  a  special  infectious  gastritis. 
There  seems  no  necessity  as  yet  for  a  separate  classification  of  this 
kind  ;  the  subject  is  still  too  hypothetical  to  be  ranked  as  equal  in 
importance  with  other  well-characterized  forms  of  gastritis.  The 
diagnosis,  prognosis,  and  treatment  are  said  by  Boas  to  be  the  same 
as  for  acute  simple  gastritis. 

Diphtheric  gastritis  is  a  rare  affection,  occurring  not  only  as 
a  sequence  to  laryngeal  and  pharyngeal  diphtheria,  but  also  as  an 
accompaniment  to  pyemia,  septicemia,  puerperal  fever,  scarlatina, 
variola,  endocarditis,  ulcerosa,  typhus,  etc.  The  disease  is,  as  a 
rule,  not  discovered  until  the  autopsy  is  made,  and  for  that  reason 
has  more  of  a  pathological  than  clinical  interest. 

Mycotic  Gastritis. — When  the  vitality  of  the  mucosa  and  the 
secretion  of  hydrochloric  acid  have  been  reduced,  suppressed,  or 
destroyed,  certain  pathogenic  fungi  are  known  to  invade  the 
mucosa,  producing  ulcerations  and  necrosis. 

Most  of  these  mycotic  gastritic  inflammations  can  not  be  recog- 
nized durincr  life  as  such.     Amone  those  that  have  been  described 


PLATE  VI. 


Bacterial   Ina^asion   of  Gastric  Epithelium.     From  a   Case  of   Diphtheric 
Gastritis. — [Hemmeter.') 


MYCOTIC    GASTRITIS.  ^  415 

are  the  anthrax  gastritis,  produced  by  spores  or  bacilli  of  anthrax 
lodging  in  the  mucosa  or  submucosa  and  giving  rise  to  inflam- 
mation, ulcertion,  and  necrosis. 

Sidney  Martin  observed  a  case  of  anthrax  of  the  anterior  wall  of 
the  stomach  at  Guy's  Hospital  ;  the  primary  infection  was  in  the  left 
cheek,  where  a  malignant  pustule  developed  [Joitrjiai  of  Pathology 
and  Bacteriology,  vol.  i). 

Gastritis  caused  by  \h^  faviis  fungus  (Achorion  Schonleinii)  has 
been  reported  by  Kundrat  ("  Ueber  Gastro-enteritis  Favosa,"  VVien. 
nied.  Blatter,  1884,  No.  49).  The  case  was  that  of  a  drunkard  whose 
gastric  mucosa  was  predisposed  by  alcoholic  chronic  gastritis  ;  he 
had  favus  universalis,  and  in  the  stomach  and  intestines  the  fungi 
had  caused  diphtheric  inflammations,  with  fibrous  exudations, 
ulceration,  and  sloughing;  death  was  caused,  it  appears,  by  a 
terminal  colitis. 

The  thrush  fungus  (German,  Soor  ;  Latin,  O'idium  albicans)  has 
been  reported  as  setting  up  a  mycotic  gastritis;  in  some  cases  in 
which  the  stomach  alone  appeared  infected,  throat  and  esophagus 
were  intact. 

The  yeast  fungus  (torulae  or  saccharomyces  cerevisiae),  sarcinse, 
the  common  molds  (penecillium  glaucum  and  mucor),  and  various 
schizomycetes  occur  in  the  gastric  contents  and  set  up  irritation  of 
the  mucosa  ;  not  by  direct  invasion,  it  appears,  but  by  the  toxic  pro- 
ducts of  the  fermentation  which  they  cause. 

Sarcinae,  according  to  Hiihne,  do  not  bring  about  any  fermenta- 
tion. 

Miller's  interesting  investigations  concerning  the  bacterial  flora 
of  the  mouth  have  been  referred  to  on  page  64.  In  the  first  volume 
of  his  excellent  text-book  ("  Specielle  pathol.  Anatomie,"  Bd.  i, 
p.  704),  Johannes  Orth  describes  an  interesting  bacterial  invasion 
near  an  old  chronic  gastric  ulcer  which  had  largely  become  healed. 
At  several  places  there  were  grayish,  bran-like  incrustations,  partly 
adherent,  which  anatomically  had  to  be  designated  as  diphtheric. 
In  the  scabs  or  crust,  and  in  the  deeper  parts  of  the  mucosa,  and 
partly  lodged  distinctly  in  lymph  vessels,  were  numerous  bacilli 
that  had  some  morphological  resemblance  to  those  of  anthrax;  this 
supposition  could,  however,  not  be  confirmed  by  cultures.  The 
case  was  complicated  by  the  fact  that  a  fatal  hemorrhage  had 
occurred  from  a  very  small  arteriole  at  a  place  where  only  a  very 
tiny  defect  in  the  mucosa  was  observable.     In  the  immediate  neigh- 


4l6  PARASITIC    GASTRITIS, 

borhood  of  this  defect  the  bacilli  were  found  also,  but  not  in  suffi- 
cient numbers  to  attribute  to  their  destructive  agency  the  tearing 
of  the  arteriole,  which  was  not  aneurysmatic. 

Orth  then  refers  to  the  bacillus  gastricus,  or  polysporous 
brevis  of  Klebs  ("  Ueber  Infectiose  Magenaffectionen,"  yJ//o-^;//^w. 
IVieu.  vied.  Zeit.,  i88i,  Nos.  29  and  30),  which  this  pathologist 
claims  to  have  found  free  in  the  lumen  of  the  glands  as  well  as 
between  the  cells  of  the  glands  and  the  tunica  propria  ;  there  was 
also  an  interglandular,  small,  round-cell  infiltration. 

Bottcher  {Dorpatcr  vied.  Zeitschr.,  1875,  p.  184)  also  defended  the 
view  that  gastric  ulcers  are  in  part  due  to  mycotic  and  bacterial 
invasions.  Unfortunately,  Klebs'  and  Bottcher's  statements  have 
not  been  confirmed  by  later  investigators. 

Animal  parasites  are  also  on  record  for  producing  gastritis.  C. 
Gerhardt  ("  Magenkatarrh  durch  lebende  Dipterenlarven,"  Jenaer 
vied.  Zeitschr.,  Bd.  iii,  S.  522)  gave  an  account  of  acute  gastritis  set 
up  by  larvae  (maggots)  of  diptera,  a  class  of  insects  of  which  the 
common  fly,  the  flea,  etc.,  are  examples.  The  eggs  of  these  larvae 
were  said  to  have  been  swallowed  with  raspberries.  Meschede 
("  Ein  Fall  von  Erkrank.  durch  im  Magen  weilende,  lebende  Maden," 
Vircliozv's  Archiv,  Bd.  xxxvi,  S.  300)  reports  gastritis  caused  by 
maggots  eaten  with  cheese.  Senator  reported  gastritis  set  up  by 
living  maggots  of  the  common  fly  which  occurred  in  the  mouth  and 
stomach  [Berlin,  klin.  WocJiensclir.,  1890,  No.  7);  the  same  observa- 
tion was  made  by  Hildebrandt  {Berlin,  klin.  WocJienschr.,  1890,  No. 
19).  Fermaud  observed  a  case  of  gastritis  and  gastralgia  caused 
by  an  earthworm  {Journal  de  Med.  Praciique  de  Paris,  1836,  tome 
\\i,  p.  57).  It  is  known  also  that  ascarides  and  tapeworms  may 
reach  the  stomach  in  rare  cases  and  give  rise  to  severe  inflamma- 
tions, which  may  subside  at  once  as  soon  as  the  offending  parasite 
is  vomited. 

Toxic  Gastritis  {Gastritis  Venenata). — This  form  of  acute  gastric 
inflammation  is  caused  by  poisons  or  corrosive  chemical  bodies. 
The  poisons  that  have  been  taken,  either  by  mistake  or  with  suicidal 
intentions,  are  mercuric  chlorid  or  corrosive  sublimate,  phos- 
phorus, arsenic,  chloroform,  creosote,  potassium  chlorate,  oxalic 
acid,  nitrobenzol,  carbolic  acid,  the  concentrated  inorganic  acids, 
sulphuric,  hydrochloric,  and  nitric  acids;  the  caustic  alkaline 
hydroxids  in  strong  solution,  and,  furthermore,  alcohol  in  all  its 
forms,  and   some  substances    used   as   medicines   (see  etiology   of 


TOXIC    GASTRITIS.  417 

acute  gastritis),  particularly  croton  oil,  antimonium  and  potassium 
tartrate  (tartar  emetic) ;  also  ammonia. 

The  patJiology  will  necessarily  vary  considerably,  as  it  is  not 
only  dependent  upon  the  kind,  but  upon  the  quantity  and  con- 
centration of  the  poison,  and  also  upon  the  circumstance  whether 
the  poison  is  taken  on  a  full  or  an  empty  stomach,  as  food  and  drink 
dilute  the  drugs.  There  may  be  only  a  slight  superficial  inflam- 
mation, or  a  very  penetrating  corrosive  effect  involving  the 
entire  gastric  wall  and  even  leading  to  perforation.  Different  drugs 
produce  different  effects  upon  the  mucosa.  Phosphorus,  arsenic, 
antimony,  and  alcohol  produce,  in  excessively  large  toxic  doses,  a 
milky,  yellowish-white,  or  opaque  appearance.  The  epithelia  of  the 
alveoli  of  the  tubular  glands  are  partly  in  a  state  of  mucoid  degen- 
eration, partly  finely  granulated,  cloudy,  and  showing  fatty  degen- 
eration ;  the  same  is  the  case  with  the  secreting  cells.  The  tissue 
between  the  cells  is  crowded  with  a  small  round-cell  infiltration. 
In  this  condition  auto-digestion  by  the  gastric  juice  may  cause 
peptic  ulcers,  i.  e.,  when  the  poisons  are  not  taken  sufficiently 
strong  to  effect  ulceration  or  to  destroy  secretion. 

Dilute  acids  and  alkalies  induce  the  pathological  picture  of  a 
simple  acute  gastritis  ;  while,  in  concentrated  form,  the  same  agents 
cause  a  deeply  penetrating  necrosis,  formation  of  crusts  and  intense 
reactive  inflammation  with  serous  infiltration,  suppuration,  and 
blood  extravasation.  The  scabs  or  crusts  show  different  colors  with 
different  corrosives.  Under  the  effect  of  sulphuric  acid  they  are 
black;  of  nitric  acid,  yellow;  of  alkalies,  brown;  of  copper  salts, 
green  or  blue  ;  of  silver  salts,  black.  Dislodgment  of  these  crusts 
leads  to  fatal  bleeding,  tearing  of  the  serosa,  or  perforation,  with 
peritonitis.  Oxalic  acid  is  said  to  produce  a  jelly-like,  semitrans- 
parent  swelling.     Ammonia  causes  a  pustular  inflammation. 

Symptoms. — After  taking  the  poison  there  is  generally  an  inde- 
scribably severe  pain,  intolerable  burning,  and  vomiting  which  in- 
creases the  pain  and  at  times  causes  fainting.  The  vomit,  as  a  rule, 
contains  blood  or  bloody  mucus  ;  the  thirst  is  great.  There  is  most 
frequently  diarrhea  containing  blood.  Severe  general  symptoms 
follow;  small,  very  fast  pulse  ;  jactitation;  delirium.  In  case  much 
of  the  poison  has  reached  the  general  circulation,  hematogenous 
icterus,  petechiae,  albuminuria,  and  hematuria  may  follow.  Death 
follows  in  a  few  hours  or  a  few  days  from  collapse ;  or  later  by  perfora- 
tion peritonitis.     Even  if  the  patients  are  tided  over  the  first  period 


41 8  TOXIC    GASTRITIS. 

of  acute  gastric  symptoms,  they  may  die  later  from  hemorrhage 
when  the  scabs  and  crusts  are  sequestrated,  or  by  the  consequences, 
i.  e.,  stenosis  of  the  esophagus,  cardia,  pylorus,  or  atrophy  of  the 
mucosa. 

The  diagnosis,  after  learning  the  history  of  the  case,  will  not  be 
difficult.  One  should  not  fail  to  make  a  thorough  examination  of 
the  mouth  and  throat,  where  the  corrosive  effect,  if  any,  will  be  evi- 
dent. An  analysis  of  the  vomit  will  probably  inform  of  the  nature 
of  the  poison. 

The  prognosis  of  severe  toxic  gastritis  is  necessarily  fatal ;  if  not 
by  the  direct  poisoning  or  first  destructive  effect  of  the  drug,  cer- 
tainly by  the  severe  secondary  effects. 

The  treatment  will  vary  with  the  nature  of  the  poison.  In  recent 
poisoning  with  strong  acids,  magnesia  usta  (calcined)  should  be 
given  as  soon  as  possible.  If  no  drug-store  is  near,  chalk,  or  even 
powdered  lime,  which  can  be  scraped  from  the  wall,  should  be  given. 
Whenever  possible,  the  stomach-tube  should  be  used  at  once  for 
all  poisoning  of  recent  date. 

Boas,  Fleischer,  and  Pick  advise  that  the  tube  should  not  be  used 
in  severe  acid  or  caustic  alkali  poisoning,  because  of  the  danger  of 
perforating  the  stomach.  As  most  such  cases  will  probably  die  of 
perforation  anyway,  we  certainly  should  use  the  tube  and  let  the 
patient  take  his  chances.  About  250  c.c.  of  water,  with  sodium 
bicarbonate  in  case  acids  were  taken,  or  vinegar  in  case  alkalies 
were  taken,  will  doubtlessly  dilute  and  combine  with  the  destruc- 
tive agent  present.  Lemon  juice  will  also  answer  for  the  alkaline 
caustics.  In  all  other  poisonings  the  stomach-tube,  or,  if  convenient, 
the  pump,  should  be  used  as  soon  as  possible,  and  the  stomach 
washed  out  thoroughly.  For  other  poisons  the  approved  antidotes 
should  be  given  (freshly  prepared  hydrated  oxid  of  iron  for  arsenic, 
etc.),  that  will  be  found  in  various  text-books  on  toxicology  and 
therapeutics  (H.  A.  Hare's  system  ;  H.  C.  Wood  ;  Lauder  Brun- 
ton  ;  Binz,  Schmiedeberg ;  Penzoldt  and  Stintzing's  system,  vol. 
vi).  After  carbolic  acid  ingestion  wash  out  the  stomach,  and  then 
pour  in  250  c.c.  olive  oil.  In  all  corrosive  poisoning  cases  the 
pouring  in  of  olive  oil  or  molten  vaselin,  after  neutralization  and 
washing  out,  will,  if  possible,  diminish  the  corrosive  effect.  Where 
not  too  much  acid  or  alkali  has  been  taken,  the  subnitrate  of  bis- 
muth or  subgallate  of  bismuth,  one  dram  three  times  a  day,  if  pos- 
sible, swallowed  with  oil,  will    favor  rapid  cicatrization  and  inhibit 


TREATMENT    OF    TOXIC    GASTRITIS.  419 

bacterial  infection  of  the  necrosed,  charred  areas.  A  suspension  of 
bismuth  subnitrate,  three  drams  to  one  pint  mucilage  and  water,  has 
proved  advantageous  in  a  case  of  carbolic  acid  poisoning  in  our 
practice;  it  was  used  in  form  of  lavage. 

If  the  pain  is  severe,  morphin  must  be  promptly  given,  hypoder- 
mically,  in  ^  to  ^  gr.  doses,  repeated  until  relief  comes.  It  is 
our  duty  to  give  relief  to  the  pain  at  any  risk,  even  if  chloroform 
anesthesia  is  required;  for  after  the  suffering  ceases  our  efforts  to 
save  the  patient  can  be  more  easily  executed.  Nutrition  must  be 
carried  on  by  rectal  enemata  only.  By  the  mouth,  ice  is  about  all 
that  is  permissible  ;  it  will  tend  to  diminish  the  pain,  fever,  and 
inflammation.  We  make  such  an  explicit  statement  of  treatment 
because  we  had  experience  with  two  cases  where  the  autopsy 
showed  that  recovery  might  have  been  possible  (as  not  much  sul- 
phuric acid  had  reached  the  stomach)  if  the  treatment  had  been  more 
heroic,  i.  e.,  if  the  tube  had  been  used  for  timely  removal  of  the 
poison. 


CHAPTER    II. 

CHRONIC    GASTRITIS. 

Little  over  a  decad  ago  it  was  customary  to  designate  all 
stomach  diseases  that  were  not  acute,  and  that  could  not  be  diag- 
nosed as  dilatation,  ulcer,  or  carcinoma,  as  "  chronic  gastric 
catarrh."  We  agree  with  Ewald  and  Penzoldt,  in  the  objections  to 
the  word  "  catarrh,"  and  have  given  the  reasons  under  the  chapter 
on  Simple  Acute  Gastritis.  Even  at  the  present  day  there  is  no 
absolute  uniformity  in  the  conception  and  limitations  of  the  term 
"  chronic  gastritis." 

With  the  aid  of  improved  methods  of  diagnosis,  particularly 
such  methods  as  permit  of  an  exact  study  of  the  various  gastric 
functions,  the  so-called  gastric  neuroses  have  been  recognized  as 
separate  and  distinct  diseases  ;  formerly  they  were  believed  to  be 
symptoms  of  chronic  gastritis.  This  chronic  inflammation  of  the 
mucosa  affects  all  the  important  functions,  although  one  or  the  other 
of  these  is  generally  most  involved.  There  are  observed  many  varia- 
tions in  kind  and  intensity  of  disturbed  function,  from  a  trivial 
reduction  of  secretion  of  gastric  juice  or  interference  with  motility, 
to  complete  suppression  of  glandular  activity  and  pronounced 
insufficiency  of  peristalsis.  There  are  two  pathological  processes 
inseparable  from  every  chronic  gastritis  ;  these  are :  degeneration 
and  desquamation  of  the  glandular  cells,  and  infiltration  of  con- 
nective tissue.  Bearing  in  mind  these  conditions,  we  may  distin- 
guish two  main  types  of  chronic  gastritis  :  first,  the  hypertrophic; 
and,  secondly,  the  atrophic.  The  hypertrophic  form  consists  of 
proliferation  of  the  connective  tissue,  leading  to  change  of  form 
and  folding  or  warty  elevations  of  the  mucosa  ("  etat  mammelone," 
or  polyposis).  The  result  of  this  process  is  :  first,  either  complete 
destruction,  or,  secondly,  cystic  degeneration  of  the  glands.  A 
grayish-brown,  or  in  places  a  dark  brown,  color  is  peculiar  to  this 
swollen  and  proliferated  mucosa,  which  is  covered  with  an  adherent, 
gray  coating  of  mucus. 

The   atrophic   form    consists   of  contraction   of  the   connective 

420 


NATURE    AND    CONXEPT    OF    CHRONIC    GASTRITIS.  42 1 

tissue,  loss  of  epithelium,  and  more  or  less  complete  destruction 
of  the  glands  ;  in  rare  instances,  superficial  ulcerations.  The  mu- 
cous membrane  is  much  thinned  out,  very  smooth,  and  of  a  grayish- 
white  or  pale  slate-gray  color.  If  this  process  attacks  the  muscu- 
laris  and  submucosa,  it  may  cause  atrophy  of  the  muscle  fibrils, 
with  or  without  thickening  of  the  entire  gastric  wall  due  to  new 
formation  of  connective  tissue.  Then,  again,  we  may  meet  with 
a  genuine  hypertrophy  of  the  muscularis,  particularly  at  the  pyloric 
portion,  or  in  the  pylorus  itself.  The  lumen  of  the  stomach  in 
these  forms  may  show  a  normal  capacity  ;  or  it  may  be  much 
diminished  in  size  by  connective-tissue  thickening  of  the  gastric 
walls  and  subsequent  contraction.  This  process  is  known  as  "  gas- 
tric cirrhosis"  (Brinton).  By  French  writers  it  is  termed  "hyper- 
trophic sclerosis  of  the  stomach  "  (Hanot  and  Gombauldt,  ArcJiiv. 
de  Physiol.,  ix,  p.  412;  also  Dubey,  Gazette  Hebdoinin,  1883, 
p.  198),  and  it  may  reduce  the  normal  capacity  to  160  c.c.  (Leube, 
Penzoldt).  Or,  again,  the  capacity  is  much  increased  by  a  dilata- 
tion in  consequence  of  chronic  gastritis  and  hypertrophic  pyloric 
stenosis.  So  the  anatomical  picture  may  present :  [a)  atroph  v  of  the 
mucosa  with  wasting  of  the  peptic  glands  and  of  the  muscularis; 
thinning  of  the  entire  gastric  wall,  and,  very  frequently,  dilatation  ; 
or,  on  the  other  hand  :  {b)  inflammatory  hyperplasia  of  the  layers  of 
the  stomach,  with  excessive  connective-tissue  proliferation  (cirrhosis 
ventriculi);  hypertrophic  pyloric  stenosis;  atrophy  of  the  glandular 
layer  and  sometimes  of  the  muscularis.  This  form  may  lead  to 
marked  reduction  of  the  lumen ;  or,  more  frequently,  if  a  stenosis 
exist,  to  a  dilatation.  Both  forms  produce  grave  disturbances  of 
motility,  secretion,  and  absorption. 

The  cause  of  the  elevated,  warty,  or  polypoid  projections  of  the 
glandular  layer  is  to  be  sought  in  the  fact  that,  in  certain  forms  of 
the  disease,  the  mucous  layer  grows  much  more  rapidly  than  the 
submucous  layer,  bringing  about  a  rough,  wrinkled,  mammillated 
surface  that  has  been  described  as  "  gastritis  polyposa,"  and  by  some 
French  writers  is  termed  "  etat  mammelone  "  (see  Orth,  "  Specielle 
pathol.  Anat,"  Bd.  i,  p.  709).  A  number  of  Germans  describe  a 
variety  of  special  forms  of  chronic  gastritis  under  the  names  of 
"saurer  Katarrh"  (sour,  or  acid,  gastritis),  "  Schleimkatarrh"  (slimy, 
or  mucous,  gastritis),  also  termed  "  gastritis  atrophicans,"  and  a 
simple  chronic  gastritis,  or  "  einfacher  Katarrh."  All  of  these 
terms  are  unfortunately  chosen  and  unscientific  because  they  are 
.      28 


422  CHRONIC    GASTRITIS. 

artificial.  The  so-called  "  saurer  Katarrh  "  is  not  a  gastritis  at  all 
(Ewald),  but  a  neurosis  of  secretion;  a  hyperacidity,  the  result  of 
secondary  irritation  of  the  mucosa. 

Etiology, — Chronic  gastritis  is  a  wide-spread  disease,  occurring 
in  all  stations  of  life,  but  most  frequently  among  the  poorer  classes, 
where  the  quality  of  the  food  may  be  so  inferior  as  to  keep  the  stom- 
ach in  a  state  of  constant  irritation.  All  the  numerous  injurious 
influences  which  arise  from  a  defective  and  inappropriate  diet  have 
been  referred  to  under  the  head  of  the  pathogenesis  of  acute  gas- 
tritis. It  may  evolve  from  the  acute  or  subacute  form,  where  the 
mucosa  has  been  damaged  by  the  altered  circulation  and  its  resist- 
ance to  disease  lessened.  It  may  arise  from  all  processes  that  lead 
to  venous  congestion  of  the  stomach,  /.  e.,  affections  of  the  organs 
of  the  portal  system,  especially  of  the  liver  and  spleen  ;  it  may  also 
be  caused  by  diseases  of  the  heart.  There  are  certain  conditions 
which  may  bring  about  a  chronic  gastritis  by  effecting  alterations 
in  the  composition  and  structure  of  the  blood ;  among  these  are : 
anemia,  chlorosis,  scrofula,  secondary  anemias  following  typhus 
and  typhoid  fevers,  the  exanthemata,  pregnancy,  tuberculosis,  dia- 
betes, gout,  and  nephritis.  Irritating  substances  brought  continu- 
ously in  contact  with  the  mucosa,  either  from  without  or  within 
{i.  e.,  from  the  blood),  are  believed  to  cause  the  disease.  Ewald 
states  that  it  may  result  from  direct  local  irritation  of  alterations  in 
the  mucosa  itself,  such  as  cicatrices  and  neoplasms.  Our  experi- 
ence is  that  in  the  vicinity  of  such  structural  changes  pre-existing 
in  the  mucosa  there  is  indeed  a  gastritis  observed,  but  it  partakes 
mostly  of  an  acute  or  subacute  type.  Among  the  most  pronounced 
causes  of  the  frequency  of  chronic  gastritis  are  :  defective  chewing 
and  insalivation,  hurried  eating  and  swallowing  of  large  pieces  of 
food,  putrefaction  of  the  mouth  from  carious  teeth,  or  the  manifold 
forms  of  stomatitis  and  gingivitis,  and,  in  this  country,  excessively 
hasty  eating,  with  the  abuse  of  ice-water  at  meals  and  of  tobacco 
and  alcoholic  liquors  between  meals.  The  majority  of  American 
people  residing  in  cities  live  under  commercial  and  social  customs 
pernicious  to  the  digestive  organs.  Foremost  among  these  con- 
ditions are  the  high  mental  pressure  evoked  by  the  demands  of 
business,  the  constant  worry  and  nervous  tension  caused  by  force 
of  competition,  the  anxiety  to  get  rich  rapidly  by  straining  all 
mental  and  physical  powers ;  all  these  things  bring  about  a  hasty, 
nervous  manner  of  taking  food.     Chewing  is  a  process  which  most 


ETIOLOGY.  423 

business  men  execute  in  a  perfunctory  manner  only,  allowing  no 
time  for  insalivation.  If  it  were  possible  they  would  gulp  the  food 
down  dry ;  as  it  will  not  go  down  that  way,  it  is  washed  down  with 
ice-water.  Tobacco  juice  is  responsible  for  much  of  this  disease; 
also  condiments  used  habitually  (pepper,  ginger,  mustard,  horse- 
radish), and  the  habitual  use  of  drugs  (arsenic,  silver  salts,  iodids). 

Chronic  gastritis  is  most  frequent  among  habitual  consumers  of 
alcoholic  liquors.  From  what  was  said,  under  acute  gastritis,  of 
the  experimental  production  by  Ebstein  of  this  disease  with  alco- 
hol, the  frequency  of  the  chronic  form  among  the  devotees  to 
Bacchus  and  Gambrinus  is  very  intelligible.  As  Ewald  correctly 
remarks,  the  disease  may  be  classified  among  those  in  which  the 
patient's  indiscretions  play  a  very  important  role.  But,  as  most 
persons  treat  their  stomachs  badly,  and  neither  eat  with  proper 
mastication,  nor  are  able  to  resist  culinary  temptations,  gastritis  is 
one  of  the  "best  nourished"  and  most  prevalent  diseases  in  the 
world.  "  Indigestion  is  the  remorse  of  a  guilty  stomach,"  says 
Ewald;  and  F.  Albin  Hoffmann  ("  Vorlesungen  iiber  allgemeine 
Therapie,"  Leipzig,  1885)  expresses  a  sentiment  that  deserves  to  be 
an  apothegm :  "  Jeder  Mcuscli  liai  den  Magen  den  er  zu  Jiaben 
verdient'"  ("  Every  one  has  the  stomach  which  he  deserves").  It  is 
not  intended  here  to  do  injustice  to  a  large  number  of  sufferers 
from  weak  stomachs,  who  take  the  greatest  possible  care  to  avoid 
dyspepsia,  and,  nevertheless,  are  liable  to  acute  or  chronic  gastritis. 
The  etiology  explains  why  the  male  sex  is  much  more  frequently 
affected  than  the  female. 

The  Pathological  Anatomy. —  The  changes  are,  as  in  the 
acute  form,  most  pronounced  in  the  pyloric  region,  and  from  here 
extend  to  the  fundus.  The  alterations  of  structure  occurring  in 
the  course  of  chronic  gastritis  present  varying  pictures,  according 
to  the  duration  of  the  disease.  In  the  later  stages  the  variations  are 
considerable,  since,  at  this  period,  the  connective-tissue  changes  may 
at  one  time  incline  to  inflammatory  hyperplasia;  at  another,  may 
show  an  atrophic  character  ;  again,  either  the  mucosa  or  submucosa 
only,  or,  in  other  instances,  the  deeper  layers,  may  be  involved,  with 
alternating  intensity  and  extent.  The  inflammatory  process  is  not 
at  all  limited  to  mucoid  degeneration  and  desquamation  of  the 
surface  epithelium,  but  pre-eminently  affects  the  glandular  elements 
and  interstitial  tissue,  whence  it  attacks  the  deeper  layers  of  the 
gastric  wall.     In  early  stages  there  is  a  general,  diffuse  redness,  due 


424  CHRONIC    GASTRITIS. 

to  hyperemia  ;  in  later  stages  this  color  exhibits  a  peculiar  pig- 
mentation, which  first  assumes  a  bluish  or  brownish  shade,  and 
finally  gets  to  be  of  a  dirty  red-brown,  or  slate-gray,  or  both.  This 
pigmentation  is  generally  limited  to  the  pyloric  region,  but,  in 
spots,  it  may  be  spread  over  other  sections  of  the  inner  surface  of 
the  stomach.  The  color  is  caused  by  blood  pigments  which  have 
become  stored  up  in  the  cells  and  interstitial  tissue;  also  by  blood- 
corpuscles  that  have  left  the  vascular  channels  and  undergone 
pigment  metamorphosis  during  the  long-standing  chronic  hyper- 
plasia. This  pigmentation  must  not  be  confounded  with  post- 
mortem discoloration. 

Inflainniatory  Hyperplasia. — In  this  form  the  gastric  mucosa  may 
either  preserve  the  velvety  appearance  peculiar  to  the  normal  inner 
surface  of  the  contracted  stomach,  or  it  may  be  covered  with 
irregular  warty  projections,  and  exhibit  immense  development  of 
the  pyloric  "  plicae  villosae."  This  is  due  generally  to  inflammatory 
infiltration  of  the  interglandular  and  subglandular  connective  tissue, 
but  particularly  to  the  same  process  occurring  in  the  connective- 
tissue  ridges  ("  Leisten  ")  existing  between  the  vestibular  entrances 
to  the  gland-ducts  ("  Vorraume"  of  the  Germans),  or  peptic-duct 
alveoli,  as  we  prefer  to  call  them.  If  these  hypertrophic-hyperplastic 
processes  are  confined  to  circumscribed  areas,  they  may  assume 
exaggerated  degrees,  forming  polypoid  proliferations,  which,  as  a 
rule,  are  attached  by  broad  bases  ;  in  consequence,  however,  of  con- 
nective-tissue contraction,  they  may  also  occur  pedunculated.  In  this 
way  papillomatous  excrescences  may  be  developed  which  project 
into  the  lumen  of  the  stomach  (Orth,  "  Gastritis  Polyposa,"  loc.  cit.,  p. 
710).  When  the  submucosais  attacked  with  inflammatory  infiltration 
and  new  formation  of  connective  tissue,  the  loose  tissue  is  first  trans- 
formed into  one  much  richer  in  cells,  subsequently,  into  a  tougher, 
more  inelastic  layer,  resulting  naturally  in  a  much  reduced  mova- 
bility  of  the  mucosa  upon  its  substratum.  When  this  chronic 
process  results  in  cicatricial  contraction  in  the  hyperplastic  sub- 
mucous tissue,  it  may  lead  either  to  partial,  localized  change  of 
form,  or  to  a  more  or  less  general,  uniform  contraction  ("Schrump- 
fung,"  "  cirrhosis  ventriculi  "  ;  "linitis  plastica,"  Brinton).  In  the 
pyloric  portion  this  process  may  lead  to  stenosis.  Frequently, 
the  muscularis  also  is  hypertrophied,  as  a  consequence  of  the 
chronic  inflammation  transmitted  through  the  submucosa.  This 
muscular  hypertrophy  is  most  pronounced  at  the  pylorus.     The 


INFLAMMATORY    HYPERPLASIA    AND    ATROPHY.  425 

localization  at  the  pylorus  of  the  maximal  intensity  of  the  inflam- 
matory process  in  the  mucosa,  submucosa,  and  the  muscularis, 
makes  the  origin  of  a  pyloric  stenosis  in  consequence  of  chronic 
gastritis  intelligible.  This  kind  of  stenosis  is  usually  spoken  of  as 
benign,  in  contradistinction  to  the  malignant  stenosis  of  carcinoma. 

Much  diversity  of  opinion  exists  concerning  the  origin  of  the 
Hat  Diainmelone  ("  mammelon  "  means  the  nipple  of  the  mammary 
gland).  Frerichs  held  that  it  was  due  to  accumulations  of  fat  in 
the  mucosa  and  inflammatory  hyperplasia  of  its  contained  h'mph- 
follicles.  Rindfleisch  maintained  that  a  greater  growth  of  the 
mucosa  than  of  the  submucosa  was  the  cause.  Ziegler  explained 
the  mucosa  polyps  by  proliferation  of  the  submucosa.  Ebstein 
assumed  an  inflammatory  hyperplasia  of  the  tissue  between  the 
glands.  Jones  assigned  as  a  cause  an  excessive  contraction  of 
single  bundles  of  the  muscularis  mucosa.  Undoubtedly,  this 
gastritis  polyposa,  with  its  mammelonated  appearance,  m.ay  be 
formed  by  a  great  diversity  of  processes. 

Iiiflamviatory  Atropliy. — The  progressive  plastic  character  of  the 
inflammation  just  depicted  may  lead  to  retrograde  metamorphosis 
before  it  has  progressed  very  far  ;  in  some  cases  it  may  not  de- 
velop at  all,  but  the  disposition  to  break  down  and  atrophy  may 
start  early  in  the  disease.  These  atrophic  changes  are  most  marked 
in  the  glandular  elements,  and  may  be  limited  to  these.  Some- 
times the  inflammations  of  the  mucosa  and  gland-cells  have,  from 
the  outset,  a  degenerative  tendenc}-,  and  no  hypertrophy  or  hyper- 
plasia enters  into  the  anatomical  picture.  The  surface  columnar 
epithelium  and  the  cylindrical  epithelium  of  the  vestibular  alveoli 
fall  prey  to  a  mucoid  degeneration  and  desquamation.  The  epi- 
thelial cells  of  the  peptic  glands  undergo  fatty  degeneration.  Dur- 
ing this  atrophy,  the  mucosa  changes  to  a  thin,  smooth,  pigmented, 
or  slate-gray  membrane.  This  atrophy  may  be  limited  to  the 
mucosa,  while,  at  the  same  time,  hypertrophic  changes  go  on  un- 
hindered in  the  submucosa  and  muscularis  ;  again,  the  atrophy  may 
extend  to  the  latter  layers,  and  bring  about  a  wasting  of  all  gastric 
strata.  This  last  condition  was  formerly  designated  "  tabes  of  the 
stomach"  (the  "  phthisis  ventriculi  "  of  Rokitansky).  Under  these 
irreparable  atrophic  states,  anomalies  in  the  gastric  volume  may 
develop,  but  dilatation  is  here  more  frequent  than  contraction. 

Atrophy  of  the  stomach  may  occur  without  preceding  chronic 
gastritis.     It  then   appears  as  a   simple   degenerative  process,  and 


426  CHRONIC    GASTRITIS. 

follows  severe  anemic,  cachectic  states,  and  also  grave  infectious 
diseases  and  poisonings. 

When  confronted  with  cases  of  gastric  atrophy,  with  absence  of 
hydrochloric  acid,  the  ferments,  and  enzymes,  and  co-existent 
anemia,  it  is  sometimes  very  difficult  to  decide  as  to  the  primary 
causative  disease.  In  these  cases  it  is  well  to  bear  in  mind  that 
anemias,  even  those  of  a  grave  pernicious  character,  may  be  a 
consequence  of,  or  rather  secondary  to,  atrophy  of  the  gastric 
mucosa  which  has  extended  to  the  intestinal  mucosa.  Our 
countryman,  Austin  Flint,  was  the  first  to  call  attention  to  the 
relation  between  anemia  and  atrophy  of  the  gastric  glands.  In 
i860  (Austin  Flint,  American  Medical  Times,  i860)  he  expressed 
the  opinion  that  some  cases  of  obscure  and  profound  anemia 
are  dependent  upon  degeneration  and  atrophy  of  the  glands  of 
the  stomach.  (Further  contributions  of  Flint  to  this  subject  are 
to  be  found  in  the  New  York  Medical  Journal,  March,  1871,  and 
in  his  "  Principles  and  Practice  of  Medicine,"  p.  477,  Philadelphia, 
1 88 1.)  Since  Flint's  publications,  cases  have  been  reported  by 
Fenwick  [TJie  Lancet,  1877,  July  7th,  et  seg.);  Quinke  (Volkmann's 
Samml.  klin.  Vortrdge,  No.  100,  case  S)\  Brabazon  {Tlie  British 
Medical  Joiu-nal,  1878,  July  27th);  Nothnagel  {Deutsch.  Archiv  f. 
klin.  Med.,  Bd.  xxiv,  p.  353);  Bartels  {Berlin,  klin.  Wochenschr., 
1888,  No.  3);  Scheperlen  {Nordisch.  Medic.  Arkiv,  1879,  Bd.  xi. 
No.  3) ;  Osier  ("  Atrophy  of  the  Stomach,  with  the  Clinical  Fea- 
tures of  Progressive  Pernicious  Anemia,"  American  Journal  Med. 
Sciences,  1886,  No.  4).  Rosenheim  reported  two  similar  cases 
which  appeared  to  be  pernicious  anemia  {Berlin,  klin.  Wochenschr., 
1888,  Nos.  51,  52). 

Inasmuch  as  these  cases  of  atrophy  of  the  gastric  mucosa  are 
accompanied  by  marked  changes  in  the  blood,  signs  of  breakdown 
in  the  red  blood-corpuscles,  increase  in  the  white  corpuscles  and 
formation  of  macrocytes  and  microcytes,  the  question  may  arise 
whether  pernicious  anemia  is  really  an  independent  disease  or  the 
result  of  gastric  atrophy.  Atrophy  of  the  mucosa, — not  secondary 
to  well-known  stomach  or  general  diseases,  but  occurring  as  a 
primary  disease, — has  been  claimed  to  exist  by  Fenwick  {loc.  cit.). 
Professor  William  H.  Welch  (Pepper's  "  Amer.  System  of  Med- 
icine," vol.  XI,  p.  616),  however,  was,  at  the  time  of  that  publication, 
of  opinion  that  the  existence  of  atrophy  of  the  stomach  as  a 
primary,  independent  disease  had  not  been  established,  the  histol- 


ULCERATIVE    PROCESSES    IN    GASTRITIS.  427 

ogical  examination  of  many  of  the  cases  reported  as  such  having 
been  defective.  Professor  Welch  has  since  modified  his  views  on 
this  subject.  From  the  statements  of  some  writers  the  impression 
might  be  gained  that  the  hypertrophic-hyperplastic  form  of  chronic 
gastritis  was,  from  its  fully  developed  stage,  changed  into  the 
atrophic  form.  This  would  mean  the  total  disappearance  of  the 
papillary,  polypoid  proliferations  of  the  "  etat  mammelone,"  because 
the  mucosa  of  the  atrophic  form  is  very  smooth.  According  to 
Orth  {loc.  cit.,  p.  710),  this  is  very  improbable,  for  he  is  of  the 
opinion  that  the  atrophic  form  is  developed  uniformly  by  trans- 
formation of  cellular  interstitial  tissue  into  contracting  cicatricial 
tissue,  bringing  about  thinning  of  the  mucosa  and  degeneration 
of  the  glandular  elements  without  the  intervening  features  of 
hyperplasia  above  referred  to. 

Ulcerative  processes  are  said  to  occur  (Ziegler,  loc.  cit.)  when,  in 
the  course  of  the  disease,  intense  (hemorrhagic)  inflammation  pro- 
duces necrosis  of  the  epithelium  and  submucosa,  and  its  subsequent 
"  sequestration."  In  this  way  the  so-called  catarrhal  gastric  ulcers 
and  hemorrhagic  erosions  are  formed,  which  may  be  associated 
with  hemorrhage.  Cruveilhier  ("Anatomie  Pathologique  du  Corps 
Humaine  ")  records  a  follicular  gastritis,  in  which  ulcers  were 
said  to  originate  in  the  follicular  glandular  apparatus. 

The  catarrhal  gastric  ulcers  of  chronic  gastritis  are  mostly  small, 
round,  or  irregularly  indentate.  They  are  supposed  to  heal  and 
form  flat  pigmented  cicatrices.  Forster  asserts  that  they  may  lead 
to  perforation.  Orth  {loc.  cit),  whose  statements  merit  confidence 
because  of  his  scientific  conservatism,  is  of  the  opinion  that  ul- 
cerative processes  in  the  course  of  chronic  gastritis  are  very  rare. 
The  minute  anatomy  of  the  process  is  that  of  a  parenchymatous 
and  interstitial  inflammation.  The  glandular  cells  are  partly  de- 
stroyed, partly  granular,  and  partly  shriveled  up  ;  differentiation 
between  the  principal  (Hauptzellen)  and  the  parietal  cells  (Beleg- 
zellen)  is  impossible.  In  many  places,  especially  in  the  pyloric 
region,  the  ducts  have  lost  their  regular  order  of  lying  alongside 
of  one  another,  and  show  atypical  manifold  ramification  like  glove 
fingers.  Isolated  glands  become  separated  at  the  fundus  and  ap- 
pear as  cysts  at  the  border  of  the  submucosa;  these  are  either 
empty,  with  a  smooth  lining  membrane,  or  are  filled  with  the  re- 
mains of  glistening  hyaline  cuboidal  epithelium.  There  is  an 
abundant  small-celled  infiltration  which  is  especially  marked  near 


428 


CHRONIC    GASTRITIS. 


the  surface  of  the  mucous  membrane  ;  the  cells  lie  between  the 
glands,  and,  in  places,  push  their  ducts  far  apart.  In  the  hyper- 
plastic form  we  see  processes  of  connective  tissue  which  proceed 
upward  between  the  glands  from  the  submucosa,  like  the  branches 
of  a  tree.     The  free  surface  of  the  glandular  layer  is  covered  with  a 


Fjg.   34. — Atrophy  and  Vacuolization  of  Glandular   Elements — Mucoid   Degeneration  of 

Peptic  Cells — Increase  of  Interstitial  Connective  Tissue — Small 

Round-Celled  Infiltration. 

In  some  places  the  glandular  elements  have  disappeared,  leaving  empty,  circular  spaces.     From  a  case 
of  chronic  (alcoholic)  gastritis  (found  in  the  wash  water). 

film  of  mucus  inclosing  many  leukocytes  and  nuclei  (Ewald).  The 
superficial  layer  of  the  epithelium  of  the  mucosa  is  loosened,  and 
can  be  separated  in  adherent  shreds,  which  may  sometimes  be 
found  in  the  wash  water  after  lavage  of  the  stomach.  In  sections, 
one  can  readily  see  the  mouths  of  the  glandular  ducts  and  the 
surrounding   epithelium.      The    epithelial   cells   of   the   vestibular 


SYMPTOMATOLOGY.  429 

alveoli  (Vorraum)  are,  for  the  greater  part,  filled  with  a  pale  mucous 
mass,  which  projects  sharply  against  the  lumen  without  any  inclos- 
ing membrane,  as  described  by  Kupffer  in  the  normal  stomach. 
Ewald  has  been  able  to  study  this  and  the  following  conditions,  in 
specimens  which  were  obtained  immediately  after  death,  or  from 
living  persons  after  resection  of  the  pylorus.  In  the  conditions 
(to  be  described  presently)  of  gastritis  mucosa  or  mucipara,  this 
mucoid  degeneration  may  be  observed  to  extend  to  the  base  of 
the  glands,  so  that  in  place  of  the  ordinary  chief  and  oxyntic  cells, 
we  find  only  cells  in  the  most  varied  stages  of  mucoid  degeneration 
(see  Fig.  34).  This  condition  is  especially  marked  in  the  pyloric 
region.  Some  isolated  cells  may  be  found  which  are  still  intact, 
the  mucus  filling  only  a  small  part  of  them,  while  the  rest  of  the  cell 
is  occupied  by  granular  protoplasm  and  a  large  nucleus.  In  others, 
the  mucus  occupies  the  greater  part  of  the  cells,  and  crowds  the 
protoplasm  and  the  flattened  nucleus  against  its  base.  In  still 
others,  the  cell  membrane  has  ruptured,  and  the  mucus  has  escaped 
into  the  lumen  of  the  duct  of  the  gland,  where  it  has  been  precipi- 
tated in  streaks  by  the  alcohol.  This  gives  rise  to  very  delicate 
figures  which  resemble  a  row  of  horseshoes  with  their  openings 
toward  the  lumen  of  the  gland.  That  this  is  really  mucus,  and  not 
the  isolated  formation  of  vacuoles  as  described  by  Stohr  and 
Sachs,  is  easily  proved  by  the  reaction  with  acetic  acid,  and  the 
grayish  color  with  hematoxylin.  Ewald  emphasizes  the  fact  that 
these  features  are  found  only  where  the  mucous  membrane  has 
been  placed  in  alcohol  while  still  warm ;  in  old  tissues  he  has 
never  met  them.  Thus  there  is  a  mucoid  degeneration  of  the 
protoplasm  of  the  cells,  which  extends  deep  down  into  the  fundus 
of  the  gland. 

Symptomatology. — As  a  general  rule,  the  onset  of  gastritis  can 
not  be  determined  with  certainty,  because,  first,  it  develops  very 
gradually  and  insidiously,  either  as  a  continuation  of  acute  gastritis 
and  of  other  diseases,  or  as  an  independent  disease  ;  and,  secondly, 
the  initial  symptoms,  not  being  very  pronounced,  are  generally 
ignored.  Only  the  sudden  aggravation  caused  by  dietetic  errors, 
and  other  injurious  influences,  lead  to  the  conclusion  that  a  serious 
disease  is  present.  The  clinical  picture  varies  considerably, 
although  the  signs  of  a  disturbed  digestion,  as  indicated  by  dys- 
pepsia, absence  of  appetite,  eructation,  nausea,  vomiting,  pressure 
and  fullness  in   the   gastric   region,  repeat  themselves   in  various 


430  CHRONIC    GASTRITIS. 

cases  ;  first  one  symptom  and  then  another  will  manifest  its  presence 
or  be  entirely  absent.  Perhaps  the  most  constant  of  the  early 
symptoms  is  absence  of  appetite. 

Absence  of  Appetite  {Anorexia). — Even  in  less  serious  attacks  this 
symptom,  as  a  rule,  exists,  and  may  eventuate  in  disgust  for  the 
customary  diet.  After  prolonged  fasting  the  patient  feels  that  the 
stomach  is  empty,  but  there  is  present  no  desire  to  eat  and  no 
hunger.  There  is,  however,  a  strong  craving  for  "  piquante,"  salty, 
or  acid  food.  It  seems  as  if  an  instinctive  knowledge  existed 
that  the  production  of  gastric  juice  is  depressed  and  that  the 
mucosa  requires  a  stronger  incentive  to  secretion.  Sometimes 
a  slight  appetite  is,  at  rare  intervals,  developed,  which,  however,  a 
very  few  mouthfuls  of  food  suffice  to  satisfy  completely.  Incident- 
ally, the  desire  for  food  will  increase  if  the  patients  force  them- 
selves to  eat ;  now  and  then  bulimia — an  intense  hunger — may 
develop  at  extraordinary  times,  e.  g.,  during  the  night ;  but  this  is 
more  frequent  in  the  neurosis  of  hypersecretion,  which  was  for- 
merly classed  as  a  gastritis.     Thirst  and  salivation  are  increased. 

Taste. — We  have  rarely  observed  a  case  of  chronic  gastritis  in 
which  there  was  not  present  one  or  more  of  the  following  compli- 
cations :  Pharyngitis,  posterior  nasal  catarrh,  laryngitis,  or  a  form 
of  stomatitis  ;  the  last  occurring  most  frequently.  This  condition 
of  the  mouth  perverts  taste,  rendering  it  pasty,  sometimes  dis- 
tinctly unpleasant,  acid,  bitter,  or  metallic.  The  breath  is  frequently 
offensive,  caused  by  caries  of  the  teeth  and  by  decomposition  on 
and  in  the  lingual  epithelium,  and  eliciting  the  remark  that  "  food 
has  no  taste."  Almost  all  foods  then  taste  alike.  Occasionally,  the 
breath  will  first  become  offensive  at  the  height  of  indigestion,  one 
or  two  hours  after  meals,  and  especially  so  after  ill-smelling  eructa- 
tions ;  this  should  lead  to  the  suspicion  that  there  is  gastric 
decomposition. 

Nausea  is  an  early  symptom,  generally  preceding  emesis  ;  it  may 
exist  by  itself  for  many  hours  without  emesis,  and  may  even  occur 
on  an  empty  stomach.  When  it  occurs  after  eating,  it  subsides 
upon  vomiting  the  food.  The  ingestion  of  food  may  diminish  or 
increase  the  nausea,  which  is  not  always  a  direct  effect  of  ingesta 
or  fermenting  contents  on  the  stomach  itself.  We  have  observed  it 
when  no  food  has  been  taken  by  the  stomach  for  ten  days,  where 
daily  lavage  has  been  carried  out  and  nutrition  conducted  by  rectal 
feeding.     This  form  of  nausea  may  be  an  effect  of  intestinal  auto- 


NAUSEA,    ERUCTATION,    VOMITING.  43 1 

intoxication  of  a  severe  type,  as  these  chronic  cases  of  gastritis  are 
occasionally  subject  to  "ptomain  storms." 

Enictation  is  in  all  cases  present  at  some  time.  The  gases 
brought  up  are  air,  carbon  dioxid ;  in  some  rare  instances,  inflam- 
mable gases,  such  as  hydrogen  and  marsh-gas,  CH4,  have  been 
eructated  (Ewald,  Rupstein).  The  gases  may  be  tasteless  and 
odorless,  or  may  have  an  offensive  after-taste  of  rancid  or  bitter 
character,  particularly  when  small  portions  of  ingesta  arise  with 
the  belching.  Sometimes  the  contents  of  the  stomach  are  very 
rich  in  organic  acids,  this  being  most  likely  when  the  motility  and 
the  secretion  of  normal  HCl  are  suppressed.  A  very  high  total 
acidity,  showing  no  free  nor  combined  HCl  at  all,  will  then  be 
composed  entirely  of  lactic,  butyric,  and  acetic  acids.  This  is  a 
very  rare  occurrence  in  chronic  gastritis  in  our  experience,  and,  as 
a  rule,  associated  with  some  disturbance  of  motility.  When  this 
acid  mass  is  forced  up  into  the  esophagus  during  the  eructations, 
a  very  annoying  heartburn,  or  pyrosis,  ensues,  which  seems 
localized  at  various  parts  of  the  gullet  or  cardia,  and  may  last  for 
hours. 

Vomiting,  though  not  so  frequent  as  in  acute  gastritis,  neverthe- 
less occurs  quite  often.  In  the  chronic  gastritis  of  drinkers  it  is 
often  a  regular  event  each  morning,  and  is  then  known  as  the 
"  morning  vomit,"  or  vomitiis  matutiniis  (water-brash),  which  Fre- 
richs  attributed  to  the  swallowing  during  the  night  of  saliva  and 
the  secretions  from  the  pharyngeal  catarrh.  The  morning  vomit  is 
usually  alkaline,  inverts  starch  to  sugar,  and  gives  the  red  rhodan- 
kalium  KCNS  reaction  with  chlorid  of  iron.  A  tough,  glassy, 
morning  vomit  occurs  in  some  patients  who  are  not  drinkers  ; 
after  severe  retching,  the  mucus  may  be  found  tinged  with  blood. 
We  have  under  observation  at  present  a  female  patient  with 
chronic  gastritis,  who  vomits  this  glassy  mucus  almost  the  moment 
she  raises  her  head  from  the  pillow  in  the  morning.  Vomiting 
which  occurs  after  meals  brings  out  food  in  a  more  or  less  partially 
digested  state,  according  to  the  duration  of  its  retention  in  the 
stomach  and  the  condition  of  the  secretions.  The  eructated 
ingesta  are  imbedded  in  tough  mucus,  and  may  be  in  a  state  ot 
fermentation.  Bile  may  form  part  of  the  admixture.  If  the  gas- 
tritis is  due  to  secondary  passive  hyperemia  ("  Stauungskatarrh") 
accompanying  hepatic  cirrhosis,  the  vomit  may  contain  blood 
from    the    rupture   of   minute   varicosities    on   the   mucosa.      The 


432  CHRONIC    GASTRITIS. 

ejected  food  contains  organic  acids  (particularly  after  carbo- 
h}'drates  have  been  ingested),  but  no  free  acids.  We  have  been 
struck  with  the  frequency  of  the  occurrence  of  excessive  amounts 
of  acetic  acid  when  the  gastritis  has  been  set  up  by  long-standing 
abuse  of  alcohol.  Yeast  cells,  sarcinse,  and  a  large  \-ariety  of  bac- 
teria may  be  present.  With  incipient  and  not  very  grave  cases 
the  ferments,  pepsin  and  rennin.are  yet  to  be  detected  ;  but,  in  later 
stages,  they  are  evident  only  after  adding  HCl  slighth'  in  excess 
of  the  deficit ;  this  really  shows  that  the  pro-enzymes,  not  the  per- 
fect ferments,  are  present.  Finally,  pepsinogen  and  rennet  zymogen 
are  absent;  and,  in  very  advanced  forms,  even  the  mucus  will  cea.'^e 
to  be  secreted.  This  last  symptom  is  an  indication  of  the  com- 
plete atrophy  of  the  mucosa. 

TJie  tongue  is  very  frequently  coated  with  a  gra\-ish-white  deposit, 
most  marked  on  the  back  and  root  of  the  organ.  The  impressions 
of  the  teeth  are  retained  by  it.  At  the  edges  and  apex  the  tongue 
presents  a  deeper  red  color,  with  swollen  papillae.  The  coating 
may  disappear  toward  evening,  to  reappear  in  the  morning. 
Henoch  [Klinik  der  UnterleibskrankJiciteii,  Berlin,  1863,  p.  382) 
holds  that  the  appearance  of  the  tongue  is  really  not  always  a 
mirror  of  the  stomach,  but  that  its  condition  is  to  be  regarded 
simpl}'  as  an  index  of  the  existing  state  of  the  oral  mucous  mem- 
brane. Certainly  the  tongue  is  the  more  frequent  organ  of  the  two 
to  first  become  diseased,  as  it  is  nearer  to  the  outer  world  and  its 
infections  than  the  stomach.  Therefore,  it  might  be  supposed  that 
catarrhal  states  of  the  tongue,  mouth,  and  throat  may  occur  more 
frequently  as  independent  diseases,  not  secondary  to  antecedent 
diseases  involving  the  stomach.  Schech  ("  Krankheiten  d.  Mund- 
hohle"),  in  addition  to  malformations  and  inherited  or  acquired 
defective  forms  of  the  mouth,  describes  16  distinct  diseases  of  the 
human  mouth,  not  including  neoplasms,  tumors,  and  results  of  ner- 
vous diseases.  Seifert  (Penzoldt  and  Stintzing's  "  Handbuch  der 
spez.  Therapie,  Bd.  iv)  describes  23  mouth  diseases.  In  the  primary 
form,  all  these  arise  in  the  mouth,  and  occur  as  secondary  forms  in 
acute  inflammatory  conditions  of  the  digestive  tract,  particularly 
after  infectious  diseases.  We  have  paid  particular  attention  to  the 
state  of  the  tongue,  esophagus,  and  stomach  at  autopsies,  and  also 
during  a  large  number  of  analyses  of  stomach  contents,  and  must 
admit  that  the  condition  of  the  tongue  is  one  of  the  most  variable 
signs  in  gastric  symptomatology.     The  cases  of  manifest  disease  of 


THE    STATE    OF    THE    TONGUE.  433 

the  Stomach  where  a  primary  disease  of  the  mouth  is  out  of  the 
question,  are  extremely  rare.  A  critical  review  of  the  etiology  of 
gastric  diseases  can  not  fail  to  evince  the  fact  that  the  prominent 
causes  can,  and  most  often  do,  affect  alike  the  mouth  and  stomach. 
The  gastric  disorders  in  which  the  tongue  is  most  frequently  unaf- 
fected are  those  associated  with  little  gastric  sepsis,  i.  e.,  ulcer 
hyperacidity,  neurasthenia  gastrica ;  whereas,  in  diseases  asso- 
ciated with  much  gastric  fermentation  or  histological  changes  in 
the  mucosa  that  may  extend  to  the  mouth,  or  involve  it  through 
circulatory  or  nervous  channels,  the  tongue  is  most  often  affected. 
These  diseases  are  gastritis,  carcinoma,  and  dilatation. 

In  reviewing  the  statements  of  most  authors  on  the  condition  of 
the  tongue,  one  can  not  fail  to  notice  a  lack  of  clearness  and  pre- 
cision, which  doubtless  indicates  that  the  relation  between  remote 
and  local  causes  is  not  well  understood  concerning  this  matter. 
A  systematic  bacteriological  and  histological  study  of  coated 
tongues  is  very  much  needed  in  association  with  gastric  diseases. 
The  attempt  to  establish  a  definite,  characteristic  condition  of  the 
tongue  for  every  gastric  disease  has  thus  far  failed.  The  ex- 
tension of  stomatitis  and  glossitis  to  the  stomach  by  the  deglu- 
tition of  infective  material  is  very  intelligible.  But  the  vari- 
ous forms  of  gastric  diseases  may  also  extend  upward,  either  by 
eructations  or  direct  cellular  continuity.  Then,  again,  the  oral  and 
gastric  cavities  are  in  intimate  correlation,  and  may  mutually  affect 
each  other  through  the  vascular  and  complex  nervous  channels. 
Fleischer  {/oc.  cit.,  p.  820)  holds  that  the  importance  of  the  coating 
of  the  tongue  as  a  sign  of  gastritis  has  been  much  overrated,  and 
that  the  tongue  may  be  clean  notwithstanding  very  evident 
chronic  gastritis  and  may  be  coated  when  this  disease  is  absent. 
Nevertheless,  he  considers  the  frequent  coincidence  of  coated 
tongue  and  gastritis  remarkable,  but  attributes  it  to  a  concomitant 
stomatitis. 

General  Nutrition. — Chronic  gastritis  of  long  standing,  left  un- 
treated, will  inevitably  affect  the  general  nutrition.  As  von  Noorden 
repeatedly  emphasizes,  "  most  dyspeptics  do  not  eat  enough,"  and  in 
consequence  of  this,  emaciation  ensues  to  such  a  degree  that  even 
physicians  suspect  a  grave  underlying  disease  (tuberculosis  or 
carcinoma)  where  there  is  only  a  chronic  gastritis.  The  absence 
of  appetite  is  most  frequently  caused  by  suppression  of  secretion 
of  HCl. 


434  CHRONIC    GASTRITIS. 

Feeling  of  pressure  and  fullness  in  the  epigastric  region  is,  in 
many  cases,  complained  of,  and  may  be  evident  on  awakening  or 
develop  after  ingestion  of  food.  The  epigastric  region  in  these 
cases  is  very  likely  to  be  arched  forward  and  outward,  and  very 
sensitive  to  pressure,  even  the  weight  of  the  clothes  being  annoy- 
ing. If  no  dilatation  exists,  the  lower  border  of  the  stomach  is 
found  in  its  natural  place.  It  must  not  be  forgotten  that  a 
stomach  may  be  dilated  considerably  and  }'et  the  lower  border  be 
found  in  normal  position,  for  the  organ  may  be  enlarged  upward 
or  laterally,  displacing  the  diaphragm.  Prof  J.  Schreiber,  of 
Konigsberg,  has  repeatedly  called  attention  to  the  fact  that  the 
horizontal  umbilical  line  is  a  misleading  landmark  by  which  to 
judge  a  dilatation,  and  that  the  upper  border  should,  in  all  cases 
of  suspected  dilatation,  be  determined  [Archivf  Verdminngskrankh., 
Bd.  II,  Heft  4).  It  may  be  possible  to  ascertain  by  palpation 
whether  the  gastric  walls  are  thickened  or  not.  If  a  dilatation  be 
present  there  exists,  generally,  a  stenosis  of  the  pylorus  ;  very 
rarely  it  is  due  to  so-called  atony.  The  feeling  of  pressure  ma}' 
increase  to  a  constant  dull  pain,  which  should,  if  it  becomes  in- 
tense, lead  to  suspicion  of  carcinoma  or  ulcer.  Some  patients 
with  chronic  gastritis  suffer  during  digestion  from  an  active  peris- 
taltic unrest  in  the  stomach  and  intestines,  their  attention  being 
directed  to  it  by  abdominal  rumbling  and  gurgling  (borborygmus). 

Conditions  of  Gastric  Contents  ;  Secretion. — The  results  of 
microscopical  and  chemical  analysis  after  test-meals,  or  of  lavage 
water  early  in  the  morning  before  any  food  has  been  taken,  will 
vary  according  to  the  particular  kind  of  chronic  gastritis  and  the 
present  state  of  the  disease.  Boas  recognizes,  with  regard  to  these 
points,  four  varieties,  viz.:  (i)Acida;  (2)  Anacida  ;  (3)  Mucosa; 
(4)  Atrophicans. 

Gastritis  Acida.  State  of  the  Secretions. — Prior  to  the  results  of 
recent  investigations,  it  had  been  uniformly  maintained  that  absence 
or  great  diminution  of  HCl  was  a  constant  symptom  of  chronic 
gastritis.  Boas  argues  that  there  is  a  form  of  typical  inflammation 
of  the  stomach — termed  by  him  "  Gastritis  Acida  " — in  which  there 
is  present  a  normal  amount  of  acid,  or  even  superacidity  (Boas, 
"  Ueber  Gastritis  Acida,"  Mittheil.  d.  Naturforscher-Versamml.  in 
Wien,  1894).  Even  the  mucus  from  the  fasting  stomach  may  turn 
Congo-paper  blue.  In  gastritis  subacida,  or  anacida,  the  free  HCl  is 
reduced  or  entirely  absent,  but  combined  HCl  still  may  be  present. 


TYPES    OF    CHRONIC    GASTRITIS.  435 

Gastritis  Anacida. — In  this  subdivision  free  HCl  is  diminished  or 
entirely  absent,  but  combined  HCl  is  still  present.  Egg-albumen 
discs  are  but  slowly  digested,  or  not  at  all,  in  the  filtrate,  even  after 
addition  of  HCl.  The  difference  between  this  and  the  atrophic  form 
is  but  one  of  degree,  as  in  the  latter  all  secretion  is  lost  com- 
pletely. 

Gastritis  Mucosa,  ox  Mucipara. — As  was  pointed  out  (page  I2i) 
before,  when  rhinitis,  laryngitis,  pharyngitis,  and  bronchitis  can  be 
eliminated,  large  quantities  of  mucus  in  the  gastric  contents,  as  a 
rule,  speak  for  chronic  gastritis  mucosa.  The  cases  not  forming 
much  mucus  are  rare.  The  mucus  formation  can  be  best 
estimated  by  washing  out  the  fasting  stomach.  There  should 
be  no  difficulty  in  differentiating  gastric  mucus  from  that  derived 
from  the  respiratory  passages.  The  former  is  generally  thin, 
clear,  glassy,  stringy,  and  flowing  ;  the  latter,  thick,  opaque,  yellow- 
ish-gray, and  lumpy.  In  the  washing  from  the  fasting  organ,  one 
frequently  finds  the  organic,  structural  form-elements  of  the 
mucosa,  minutely  described  in  the  last  chapter  (and  on  p.  129). 
If  these  bits  of  mucosa  are  found  at  repeated  washings,  showing 
these  elements  either  in  conglomeration  or  singly,  there  can  be  no 
doubt  of  the  existence  of  glandular  chronic  gastritis.  Frequently 
the  morning  contents  of  the  fasting  organ  show  numerous  leuko- 
cytes. The  contents  should  be  drawn  by  expression;  if  possible, 
without  using  water.  In  gastritis  chronica  mucipara  the  contents 
may  show  a  normal  amount  of  HCl,  or  may  be  either  neutral  or 
alkaline. 

Gastritis  Atrophicans. — In  this  variety  both  free  and  combined 
HCl  are  absent,  and  the  tests  for  enzymes  and  pro-enzymes  are 
negative.  Milk  taken  or  poured  into  the  stomach  is  returned 
mostly  in  unchanged  condition.  Martius  and  Liittke  [loc.  cit^,  von 
Noorden,  and  others,  maintain  that  absolute  disappearance  of  pepsin 
and  rennin  is  never  seen.  From  large  clinical  experience  we  are 
prepared  to  state  that  the  end  stages  of  atrophic  gastritis  give  no 
evidence  of  ferments  in  gastric  contents  by  any  of  the  known  tests. 
Nor  would  it  be  rational  to  suppose  that  in  hypertrophic  gastritis, 
in  which  the  stomach  is  converted  into  a  hyperplastic,  dense,  hard 
mass  of  muscle  and  connective  tissue,  with  no  histological  remnant 
of  a  glandular. layer,  there  should  be  any  possibility  of  the  forma- 
tion of  enzymes.  In  atrophic  gastritis,  more  than  in  the  other  forms, 
there  are  very  characteristic,  lancinating  pains. 


436  CHRONIC    GASTRITIS. 

The  digestion  of  albumin  discs  or  fibrin  in  the  thermostat  is 
much  retarded,  or  may  be  wanting  entirely,  denoting  the  suppres- 
sion of  the  secretion  of  pepsin. 

Disappearance  of  rennin  and  its  zymogen  goes  on  simultaneously 
with  that  of  pepsin.  In  cases  with  loss  of  rennin  the  zymogen  of 
this  ferment  must  be  tested  for.  Among  other  observers,  Bouveret 
("  La  pepsine  et  le  ferment  lab.,"  Gac.  Med.  de  Paris,  1893,  No.  22) 
declares  that  the  absence  of  this  zymogen  is  an  important  criterion  of 
the  degree  to  which  the  destructive  process  has  advanced.  For 
the  same  purpose,  Jaworski  suggests  the  introduction  of  decinor- 
mal  solutions  of  hydrochloric  acid  into  the  stomach,  to  awaken 
any  slumbering  remnants  of  pro-enzyme  formation  and  convert  them 
into  perfect  enzymes.  In  no  case  that  shows  the  presence  of 
rennin  zymogen  need  hope  of  complete  or  partial  restitution  be 
resigned. 

Age. — This  is  pre-eminently  a  disease  affecting  adults,  for  the 
young  are  not  so  liable  to  abuse  their  stomachs,  or  so  subject  to 
the  manifold  factors  composing  the  etiology;  besides,  their  recon- 
structive and  compensatory  powers  are  greater.  The  majority  of 
cases  are  over  forty  years  of  age,  but  Litten  {Zeitsclir.  f.  kliii.  Med., 
Bd.  XIV,  S.  573)  has  reported  a  case  of  eighteen  years,  and  Einhorn 
one  of  twenty-one  years.  The  case  of  Westphalen  {St.  Peterslnirger 
med.  Wochensclir.,  1890,  Nos.  37  and  38)  was,  however,  verified  by 
autopsy;  it  occurred  in  a  young  man  twenty-eight  years  old.  We 
have  had  under  our  personal  observation  since  1888  a  young  prin- 
ter, at  that  time  in  his  twentieth  year,  whose  case  showed  absence 
of  enzymes  and  HCl,  with  much  mucus.  Numerous  leukocytes 
were  evident  in  the  contents  (mucus)  before  food  had  been 
taken.  Although  we  have  frequently  since  analyzed  his  stomach 
contents,  no  hydrochloric  acid  or  pro-enzymes  have  ever  been 
detected.  But  on  several  occasions  there  appeared  fragments  of 
gastric  mucosa,  showing  glandular  atrophy  and  chronic  inflam- 
mation. 

The  condition  of  the  boivels  most  frequently  exhibits  constipation. 
Absence  of  the  antiseptic  action  of  hydrochloric  acid  favors  intes- 
tinal fermentation,  flatulence,  and  meteorism.  When  there  is  much 
decomposition  of  ingesta,  intestinal  irritation  will  eventualh'  set  in, 
accompanied  by  diarrhea. 

Tlie  urine  is  rich  in  urates  and  phosphates  and  often  gives  a 
strong  indican  reaction.     The  total  acidity  of  the  urine  is  reduced. 


MOTOR    FUNCTION    IN    CHRONIC    GASTRITIS.  437 

The  general  health  is  variable ;  the  body  weight  may  either  be 
reduced  or  remain  constant  for  years:  this  last  indicates  that 
the  intestinal  digestion  is  good.  Many  changes  of  the  general 
condition,  from  good  to  bad  and  vice  versa,  may  occur,  but  as 
the  chronic  inflammation  progresses  there  are  marked  symptoms 
of  general  discomfort  and  indisposition  to  bodily  or  mental  exertion. 
The  least  exertion  rapidly  tires,  bringing  on  pains  in  the  limbs,  and 
despite  this  exhaustion  there  may  be  insomnia.  This  leads  to  a 
depression  of  spirit  which  may  control  the  entire  mentality,  and 
brings  on  hypochondriasis  and  melancholia.  This  leads  us  to 
refer  to  the  psychic  and  nervous  symptoms,  of  which  there  may  be 
many,  beginning  with  timidity  and  worry  at  every  new  symptom, 
precordial  fear,  oppression,  and  cardiac  palpitation  accompanied  by 
occasional  attacks  of  dyspnea.  The  so-called  stomach  vertigo, 
first  described  by  Trousseau,  we  have  never  observed  in  chronic 
gastritis,  nor  the  agarophobia  (/.  e.,  terror  in  crossing  wide  and 
empty  localities  alone)  which  Fleischer  {loc.  cit)  says  occurs  as  a 
psychic  accompaniment.  From  practical  observation  on  many 
cases,  we  are  disposed  to  believe  that  these  psychic  and  nervous  phe- 
nomena have  been  exaggerated,  as  they  occur  only  in  very  pro- 
tracted cases,  and  then  even  inconstantly. 

Disturbances  of  Motility. — A  great  number  of  cases  of  chronic 
gastritis  have  been  examined  at  the  Maryland  General  Hospital 
with  regard  to  the  peristalsis;  and,  in  the  large  majority,  this  has 
been  found  normal,  or  slightly  exaggerated.  We  use  the  method 
described  on  pages  76—80.  Boas  declares  that  he  has  never 
observed  a  dilatation  arise  from  a  chronic  gastritis  ("  Diagnostik 
u.  Therap.  d.  Magenkrankh.,"  2d  edition,  p.  21).  It  is  evident 
that  stenosis  of  the  pylorus  can  occur  which  is  not  caused  by 
cicatricial  contraction  nor  by  neoplasm,  but  by  hyperplasia  of  the 
muscular  sphincter  of  the  pyloric  region.  If  a  chronic  gastritis 
lasts  long  enough,  it  is  a  fair  presumption  that  it  may  result  in  a 
gastrectasia,  due  either  to  atrophy  of  the  muscularis  from  connec- 
tive-tissue invasion,  or  to  the  muscular  hyperplasia,  producing  a 
stenosis.  Boas  has  also  conclusively  shown  that  lactic  acid  is  not, 
as  a  rule,  formed  in  glandular  gastritis. 

Complications. — The  most  frequent  is  the  extension  of  the  in- 
flammation to  the  intestines.     The  frequent  association  of  chronic 
duodenitis  with   the   disease  explains  the  occurrence  of   catarrhal 
icterus,  which  is  an  extension  of  the  intestinal  inflammation  to  the 
29 


438  CHRONIC    GASTRITIS. 

gall-ducts.  The  results  of  chronic  gastritis  are,  in  protracted  cases 
(particularly  where  the  intestines  have  been  involved),  marked  dis- 
turbances of  nutrition  and  anemia,  which,  as  we  have  had  occasion 
to  observe,  may  assume  very  serious  forms. 

The  duration  may  vary  from  several  months  to  years,  particu- 
larly if  the  patients  have  not  the  means  nor  the  will-power  to  follow 
dietetic  regime. 

Atypical  forms  of  chronic  gastritis  are  by  no  means  rare 
occurrences,  and  sometimes  make  a  clear  diagnosis  very  difficult. 
In  the  foregoing  description  of  the  disease,  the  lack  of  very  charac- 
teristic and  peculiar  symptoms  is  evident.  In  addition  to  this,  the 
symptoms  of  loss  of  appetite,  pressure,  fullness,  eructation,  vomit- 
ing of  mucus,  may  be  absent  in  atypical  forms,  and  it  has  been  ob- 
served that  chronic  gastritis  may  run  its  course  in  a  latent,  unde- 
tected manner.  Again,  it  may  exist  under  the  manifestations  of  a 
nervous  dyspepsia,  or  there  may  be  such  prominent  intestinal 
symptoms  as  to  disguise  the  gastritis. 

Diagnosis. — The  determination  of  chronic  gastritis  is  one  of  the 
most  uncertain  things  in  the  domain  of  digestive  clinical  pathology. 
It  requires  careful  study  not  only  to  distinguish  chronic  gastritis 
from  other  diseases,  but  also  to  distinguish  the  simple,  mucous, 
atrophic,  and  chronic  gastritis  acida  (of  Boas)  from  each  other.  As 
a  rule,  the  primary  and  secondary  forms  can  be  distinguished 
without  much  difficulty.  Generally  speaking,  the  diagnosis  of 
chronic  gastritis  can  only  be  satisfactorily  established  after  the  pos- 
sibility of  the  existence  of  other  affections  of  the  stomach  has  been 
excluded.  This  disease  may  strikingly  resemble  the  clinical  pic- 
tures of  the  gastric  neuroses,  of  ulcer,  and  even  carcinoma.  As 
dilatation  is  a  very  rare  complication,  it  is  not  a  confusing  factor  in 
diagnosis.  One  should  not  make  the  diagnosis  definite  at  the  first 
examination,  but  reserve  opinion  until  the  patient  has  been  studied 
during  three  or  four  visits.  It  has,  in  some  cases,  taken  a  much 
longer  time  than  that  to  obtain  satisfactory  evidence  of  the  disease. 
The  best  evidence  is  afforded  by  repeated  microscopical  and  chemi- 
cal examination  of  the  wash-water  and  test-meals. 

It  will  be  necessary  to  dwell  upon  the  differential  diagnosis 
between  chronic  gastritis  and  the  neuroses,  ulcer,  and  carcinoma  : 
The  neuroses  may  present  all  the  symptoms  of  a  chronic  gastritis, 
particularly  the  absence  of  HCl;  but,  after  patient  and  repeated 
test-meal  analysis,  it  will  be  found  that  the  neuroses  will  some  day 


DIFFERENTIAL    DIAGNOSIS.  439 

show  a  normal  and  even  excessive  amount  of  HCl.  The  course  to 
pursue  is  to  wait  for  this  evidence.  The  presence  of  much  mucus, 
epithelial  cells,  and  leukocytes  in  the  wash-water  from  the  jejune 
stomach  indicates  chronic  gastritis.  Demonstration  of  enzymes 
and  pro-enzymes  is  very  valuable,  as  a  normal  amount  of  pepsin 
and  rennin  (when  HCl  is  absent),  speaks  for  neurosis  and  against 
gastritis.  In  the  absence  of  HCl,  Jaworski's  method  of  pouring 
in  decinormal  HCl  should  be  used  to  stimulate  the  formation  of 
enzymes. 

In  the  incipient  stage  of  chronic  gastritis,  the  enzymes  may  be 
present,  even  in  normal  amount ;  but  they  disappear  gradually  as 
the  disease  progresses.  By  the  time  the  physician  is  consulted,  the 
enzymes  are  very  much  diminished  or  entirely  absent ;  and,  accord- 
ing to  Boas,  this  is  an  indication  of  an  inflammation  of  the  mucosa, 
not  a  neurosis. 

The  differential  diagnosis  between  idiopathic  chronic  gastritis  and 
ulcer  is  decided  by  the  symptom  of  pain,  which  is  always  present 
in  ulcer,  and  usually  absent  in  chronic  gastritis.  The  ulcer-pain  is 
localized,  well  circumscribed,  very  intense,  and  occurs  at  definite 
times  after  partaking  of  food.  Hematemesis,  of  course,  points  to 
ulcer.  The  vomit  of  ulcer  shows  hyperacidity,  which  is,  as  a  rule, 
absent  in  gastritis.  In  atrophic  gastritis  there  may  be  lancinating 
pains,  but  they  are  not  so  frequent  or  constant  as  in  ulcer. 

From  carcinoma  the  differentiation  is  very  difficult  when  no 
palpable  tumor  can  be  detected.  This  is  intelligible  when  one  re- 
flects that  carcinoma  is  generally  complicated  with  chronic  gastritis. 
If  a  pyloric  carcinoma  be  present,  the  most  noteworthy  symptoms 
are :  stenosis,  motor  insufficiency,  and  stagnation  of  food  with 
large  amounts  of  lactic  acid.  A  carcinoma  seems  to  strike  a 
stomach  suddenly  with  very  severe  symptoms  and  general  disturb- 
ances— pain,  emaciation,  and  vomiting ;  whereas,  chronic  gastritis 
is  characterized  by  slow  increase  of  the  gravity  of  symptoms,  with 
alternating  improvements  and  aggravations.  It  is  an  important 
fact  that  the  motility  is  not  disturbed  in  chronic  gastritis,  and, 
therefore,  the  jejune  stomach  rarely  contains  anything  but  mucus, 
isolated  cells,  and  leukocytes.  But  in  carcinoma  the  peristalsis  is 
seriously  impeded  from  the  onset,  and  therefore  there  must  be 
stagnation,  retention,  and  acid-fermentation.  These  products  of 
retained  ingesta  occur  even  where  there  is  no  stenosis  of  the  py- 
lorus, as  a  result  of  carcinomatous  invasion  of  the  muscularis.    Gas- 


440 


CHRONIC    GASTRITIS. 


trectasia  is  an  exceedingly  rare  result  of  gastritis,  and  can  only 
occur  from  hyperplastic  thickening  of  the  pylorus,  a  thing  seldom 
reported  in  the  literature  of  this  subject.  As  stated  before,  the 
presence  of  marked  amounts  of  lactic  acid  is  not  observed  in  gas- 
tritis, but  in  carcinoma  its  occurrence  is  very  frequent.  Organic  acids 
are  rare  in  the  test-meals  of  gastritis,  whereas  in  carcinoma  there 
is,  as  a  rule,  an  excess  of  lactic  and  fatty  acids  early  in  the  disease 
(Boas,  loc.  cit).  For  further  differentiation  see  article  on  Car- 
cinoma. 

Synopsis  of  diagnostic  points  in  various  types  of  chronic  gastritis : 


Contents  of  Fasting 
Stomach. 


Acidity. 


(i)  Simple  Chronic  Limited  amount  of 
Gastritis.  watery    mucus; 

Subacid  or  anacid.  leukocytes;    epi- 

thelial cells; 
round  cells. 

(2)  Chronic  Mucus  Much  mucus;  epi- 
Gastritis.  thelial  fragments. 


(3)  Chronic  Atro- 
phic Gastritis. 

Lancinating  pains 
present  in  this  form. 

(4)  Acid  Gastritis. 


Variable  free  HCl 
rarely  present,  but 
if  present  lessened 
in  amount;  com- 
bined IICl  present. 

At  the  beginning 
there  may  be  a 
normal  amount  of 
free  HCl,  later  on 
the  amount  is  low; 
HCl  absent ;  HCl 
deficit. 


Empty;  no  mucus,  i  HCl  absent;  HCl 
deficit ;  no  com- 
bined HCl. 


Pepsin  and  rennin  pres- 
ent in  small  amount; 
propeptone  formed 
in  the  stomach. 


Pepsin  absent ;  rennin 
absent ;  both  pro-en- 
zymes present ;  ex- 
perimental digestion 
occurs  on  supplying 
the  HCl  deficit. 


No  enzymes  ;  no  pro- 
enzymes ;  no  curd- 
ling of  milk  on  add- 
ing HCl. 


Much  mucus ;  giving  '  Normal  amount  HCl,  Ferments  increased. 
HCl  reaction.  j     or  hyperacidity. 


Prognosis. — Chronic  gastritis  is  a  tedious,  but  not  a  very  seri- 
ous affection,  as  many  cases  recover  under  suitable  treatment.  The 
prognosis  must  vary  with  the  stage  of  the  disease  as  presented, 
and  the  intelligence  and  will-power  of  the  patient.  Patients  who 
will  study  to  avoid  further  detrimental  influences,  and  who  have 
the  determination  to  carry  out  the  dietetic  and  hygienic  manage- 
ment, will  recover.  With  incorrigible  eaters  or  drinkers,  who  re- 
transgress  against  their  stomachs  on  the  slightest  improvement, 
permanent  recovery  is  doubtful.  After  the  establishment  of  partial 
or  complete  atrophy  of  the  glandular  mucosa,  perfect  recovery 
is  impossible;  but,  as  it  is  well  known  that  a  good  state  of  general 


TREATMENT.  44I 

health  may  be  maintained  with  complete  suppression  of  the  gastric 
juice,  provided  the  intestines  still  function  normally,  atrophy  of  the 
mucosa  need  not  necessarily  imperil  vitality.  On  the  other  hand, 
there  are  numerous  well-authenticated  observations  (see  literature) 
that  demonstrate  severe  disturbances  of  nutrition,  particularly  per- 
nicious anemia,  as  a  consequence  of  gastric  atrophy.  Fenwick 
{loc.cit})  suggests  that  this  pernicious  anemia  may  be  due  to  auto- 
intoxication from  the  stomach.  Other  authors,  again,  hold  that 
the  anemia  may  be  the  primary  factor,  and  bring  about  the  atrophy 
of  the  mucosa.  This  entire  question  still  partakes  of  a  speculative 
nature,  since  exact  and  logical  experiments  and  deductions  are 
wanting. 

Treatment.  Propliylactic  Treatment. — The  prevention  of  the 
development -of  the  disease  implies  avoidance  of  the  causes  given 
under  the  head  of  etiology  of  acute  and  chronic  gastritis.  Special 
attention  should  be  directed  to  the  avoidance  of  continued  abuse 
of  alcohol.  Every  acute  gastritis,  be  it  an  independent,  idiopathic 
affection,  or  secondary  to  other  diseases,  must  be  carefully  treated 
in  order  to  prevent  its  transition  into  the  chronic  form.  Explicit 
directions  regarding  diet  and  mode  of  life  must  be  given  to  all 
sufferers  from  liver,  lung,  heart,  and  kidney  diseases ;  also  to 
diabetics,  in  order  that  they  may  be  saved  from  secondary  gastritis, 
for  disturbances  of  appetite  and  impairment  of  digestive  powers 
must  inevitably  render  the  fundamental  disease  more  serious. 

The  chief  predisposing  factors  in  chronic  gastritis  are  passive 
congestion  and  accumulation  of  injurious  metabolic  products  in 
the  heart  muscle,  with  renal  insufficiency.  In  cases  of  threatened 
passive  engorgement,  digitalis  should  be  used  early.  One  need 
not  fear  the  appetite-disturbing  effect  of  the  medicine,  as  this  is 
usually  transient,  and  we  can  confirm  Leube's  statement  that  an 
improvement  of  the  appetite'  and  of  nutrition  in  general  is  observed 
after  treatment  by  digitalis,  we  usually  combine  it  with  large  doses 
of  strychnin.  The  passive  engorgement  of  the  mucosa  is  more 
harmful  than  the  drug.  If  it  is  noticed  in  several  attacks  that 
the  gastric  symptoms  improve  on  administration  of  digitalis,  it 
is  expedient  to  give  the  remedy  at  the  outset  of  the  slightest 
disturbance  of  appetite,  since  our  experience  has  taught  us 
that  this  will  unfailingly  become  aggravated  by  delay  in  the  use 
of  the  heart  tonic.  If  the  stomach  rebels  against  the  remedy,  the 
infusion    should    be    given    by    enema    into   a   rectum    previously 


442  CHRONIC    GASTRITIS. 

cleaned  by  warm  normal  salt  irrigation,  or  digitalin  injected  hypo- 
dermically. 

Lavage. — When  it  is  no  longer  possible  to  remove  the  causes 
that  lead  to  a  chronic  gastritis,  we   may  yet  be   able  to  remove 
those  that  maintain  or  aggravate  the  malady.     These  causes  are  : 
the  accumulation  of  mucus,  and  the  mechanical  as  well  as  chemi- 
cal irritation  of  the  stagnating  contents,  particularly  when  atony 
and  hypertrophic  stenosis  exist.     To  accomplish  this,  emetics  are 
impracticable,  because  they  rarely  effect  a  thorough  cleansing,  and 
may  increase  the  inflammation  by  the  convulsive  contractions  the}' 
excite  and  by  their  direct  irritation.     If  an  emetic  is  absolutely  not 
to  be  avoided,  apomorphin  hypodermically  is  the  safest.     Purga- 
tives are   even    more   deleterious,  for   several   reasons :  first,  they 
also  increase  gastric  irritation ;  secondly,  they  can  not  be  used  habit- 
ually; and,  thirdly,  they  hurry  decomposing  masses  into  the  intes- 
tines, thereby   precipitating   an   involvement  of  this  tract  and  the 
dangers  of  intestinal   putrefaction  and   auto-intoxication.     Lavage 
is  the  only  correct  procedure  in  chronic  gastritis  wherever  increase 
of  mucus,  absence  of  HCl,  decomposition,  and  a  protracted  stomach 
digestion  are   evident.     The  mucus  often  adheres  very  tightly  to 
the  gastric  walls,  since  it  only  appears,  as  a  rule,  toward  the  close 
of  the  washing.     Its  evacuation  is  facilitated  by  allowing  the  water 
to  run  in  under  high  pressure,  and  directing  the  patient  to  change 
his  position — i.  e.,  lying  on  his  back,  rising  or  turning  on  his  side — 
during  the  lavage ;  or  by  employment  of  gastric  massage.     The 
solution  of  the  mucus  is  effectually  accomplished  by  adding  one 
tablespoonful  of  salt  and  two  tablespoonfuls  of  sodium  bicarbonate 
or  biborate  to  a  liter  of  warm  water.    To  disinfect  the  stomach  after 
the  removal  of  mucus  and  fermenting  ingesta,  the  following  reme- 
dies are  approved  aids:  Salicylic  acid,  I  :  looo;  thymol,  0.5  :  looo; 
boracic  acid,    10:  1000;  chloroform   water,  5   to    10:  lOOO;  shake 
the  chloroform  with  the  water,  and  after  settling  pour  off  the  water, 
using  only  the  latter;  hydrochloric  acid,  8  :  lOOO;   resorcin   resub- 
limate,  10:  1000  ;  benzol,  5  :  lOOO.     The  solution  must  be  prepared 
immediately  before  the  washing. 

The  frequency  of  the  lavage  depends  upon  the  state  of  the 
stomach.  There  may  be  cases  that  do  not  require  it  oftener  than 
once  in  two  or  three  days ;  others  require  it  twice  in  twenty-four 
hours  ;  usually,  once  a  day  is  sufficient.  The  time  of  the  washing 
should  be  so  selected  that  the  exhausted  stomach  may  enjoy  the 


DIETETIC    TREATMENT.  443 

longest  possible  rest.  For  this  purpose  six  o'clock  in  the  evening 
is  most  suitable,  as  it  is  then  about  six  hours  after  the  main  meal 
of  the  day,  and  only  very  light  diet  is  taken  after  the  lavage  ahd 
before  bedtime.  In  other  cases  this  hour  may  be  inconvenient, 
and  an  early  hour  before  breakfast  must  be  chosen.  Washing  out 
the  stomach  is  advisable  only  when  there  is  much  formation  of 
mucus  and  where  there  may  be  stagnation  of  food.  In  atrophic 
or  chronic  gastritis  without  much  mucus,  frequent  lavage  is  not 
necessary.  In  these  cases  the  stomach-tube  is  recommended,  not 
to  remove  fermenting  ingesta  or  mucus,  but  to  treat  the  mucosa 
directly,  to  stimulate  its  sluggish  secretion  by  irrigating  with  deci- 
normal  solution  of  HCl;  if  enzymes  are  still  to  be  detected,  com- 
mon salt  solutions  are  useful  for  this  purpose  (about  one  tablespoon- 
ful  to  the  quart).  Solutions  of  NaCl  must  not  exceed  the  strength 
of  one  per  cent.,  as  solutions  of  four  per  cent.  NaCl  check  the  HCl 
secretion  and  are  available  in  the  treatment  of  hyperacidity  (see 
"  Achylia  Gastrica  "). 

Dietetic  Treatment. — In  each  case  it  is  advisable  to  give  the 
patient  a  written  diet-list,  based  upon  a  chemical  study  of  the  indi- 
vidual's digestive  power.  Sometimes  it  will  be  impossible  to  give 
a  diet  at  first  that  will  at  the  same  time  suit  the  patient's  palate  and 
digestive  power.  The  most  digestible  food  will  at  times  disagree 
with  chronic  gastritics,  and  food  which  would  seem  a  priori  w cry 
indigestible,  agrees  well.  A  good  plan  is  to  inquire  minutely  into 
each  patient's  accustomed  diet  and  ascertain  what  food  especially 
disagrees.  At  the  beginning,  the  diet  should  be  of  a  light  kind  ; 
one  that  makes  but  slight  demands  upon  the  working  capacity  of 
the  stomach.  As  the  motility  is  good  in  this  trouble,  the  diet,  as 
far  as  possible,  should  be  liquid  or  semi-liquid,  and  four  to  six  small 
meals  per  day  are  preferable  to  three  large  ones.  Nutritious  soups, 
such  as  beef  bouillon  enriched  by  the  addition  of  butter,  eggs,  beef- 
meal  or  jelly,  somatose,  or  peptone,  are  generally  well  borne,  but 
as  a  rule  do  not  suffice  to  maintain  strength  and  body  weight.  It 
is  well  to  insist  on  slow  eating,  thorough  chewing,  and  insalivation 
as  important.  The  teeth  should  be  looked  after,  and,  if  necessary, 
repaired,  or  artificial  ones  provided.  Should  there  be  a  normal 
amount  of  HCl  and  pepsin  secreted,  then  a  diet  rich  in  proteid 
will  be  advisable.  Suitable  articles  of  diet  are  all  meats,  fish,  and 
eggs,  properly  prepared  ;  which  means  that  the  roasts  or  broiled 
meats,  even  after  they  are  on  the  table,  must  be  very  finely  divided 


/\^,]  CHRONIC    GASTRITIS. 

on  the  plate,  before  placing  in  the  mouth.  Light  vegetables  are 
permissible  in  form  of  purees,  viz.:  potatoes  mashed  in  milk,  peas 
or  beans  driven  through  a  sieve,  spinach,  etc.  When  the  HCl, 
although  present,  is  considerably  reduced,  the  diet  will  be  similar ; 
but  spices  and  well-salted  food  are  more  adapted.  If  the  secretion 
is  completely  suppressed,  it  is  not  expedient  to  greatly  restrict  the 
diet,  as  these  patients  are  more  liable  to  suffer  from  inanition.  The 
greatest  care  is  to  be  employed  in  the  preparation  of  the  food, 
which  must  be  presented  in  an  appetizing  and  finely  divided  form. 
All  meats  and  fish  must  be  prepared  in  the  steam  broiler,  and,  if 
needed,  they  should  be  previously  minced  and  then  re-formed  into 
any  desirable  shape,  held  by  a  supporting  substance  such  as  ex- 
perienced cooks  are  familiar  with,  generally  consisting  of  bread 
crumbs,  eggs,  salt,  and  butter.  Milk,  if  it  agrees  well,  is  a  valuable 
adjunct  to  the  diet,  and  even  if  not  well  digested,  or  if  there  is  an 
aversion  to  it,  should  be  surreptitiously  added  to  soups,  chocolate, 
rice,  sago,  gelatins,  and  farinaceous  foods.  When  it  is  thus  mixed 
with  other  foods  it  is  generally  very  well  digested,  and  adds  to 
their  nourishing  quality.  Von  Mehring  has  recommended  a  choco- 
late (Kraftchocolade)  which  contains  20  per  cent,  of  fat ;  it  is  very 
palatable  and  usually  causes  no  digestive  distress.  When  there 
is  emaciation  we  give  small  amounts  of  alcohol,  upon  the  authority 
of  Chittenden's  experiments,  that  alcohol  up  to  three  per  cent, 
favors  the  formation  of  peptone  and  amylolysis.  If  we  are  sure, 
from  test-meals,  that  there  is  no  gastric  fermentation  (and  accord- 
ing to  our  experience  there  rarely  is  in  chronic  gastritis),  we  recom- 
mend the  genuine  Oporto,  Malaga,  or  imported  Hungarian  Tokay 
wines  (J.  Palugyay  &  Sons,  Pressburg).  When  it  is  evident  that 
the  gastritis  was  caused  by  bacchanalian  excess,  it  is,  naturally,  a 
good  plan  to  exclude  alcohol  as  far  as  possible.  Indeed,  when  the 
emaciation  is  not  marked,  or  where,  after  a  trial,  the  collective 
symptoms  appear  to  become  worse,  alcoholics  are  best  avoided. 
There  are,  however,  cases  of  distinct  alcoholic  gastritis  in  which, 
after  well-observed  test-meals,  the  proteolysis  is  carried  on  better 
when  wine  is  taken.*  The  wines  we  have  recommended  have  not 
only  a  stimulating,  but,  on  account  of  their  large  percentage  of 


*The  "rationale  "  of  the  administration  of  alcohol  is  governed  by  its  effects  on  the 
gastric  digestion  as  observed  in  test-meal  analysis — if  it  impedes  digestion  it  must  be 
forbidden. 


DIETETIC    TREATMENT.  445 

grape  sugar,  a  nutritive  value.  This  grape  sugar  will,  however, 
increase  the  lactic  acid  formation  if  it  be  already  present.  In  this 
last  case  a  standard  champagne — Mumm's  Extra  Dry,"  Roederer," 
Piper-Heidsick — is  preferable.  Beer  and  claret  are,  according  to 
our  experience,  not  well  borne,  and  frequently  augment  gastric  dis- 
tress. In  cases  of  marked  anorexia  a  palatable  dilution  of  brandy 
or  whisky,  taken  half  an  hour  before  meal  times,  very  often  pro- 
duces an  appetite.  The  so-called  "  Angostura  Cocktail  "  is  some- 
times useful  to  sufferers  from  anorexia.  The  physiological  reasons 
for  the  administration  of  alcohol  are  explained  in  the  chapter  on  The 
Dietetics  of  Alcoholic  Beverages  (also  in  the  Dietetic  and  Hygienic 
Gazette,  May,  1896,  p.  289;  and  R.  H.  Chittenden,  Amer.  Jonr. 
Med.  Sciences,  Jan.  to  April,  1896,  "  Influences  of  Alcohol  on  the 
Chemical  Processes  of  Digestion"). 

Constipation  in  chronic  gastritis  should  always  be  treated  diet- 
etically,  never  by  medicines  per  os.  A  glass  of  cold  water, 
or,  preferably,  of  Bedford  Magnesia  Spring  water,  before  break- 
fast, is  a  simple  thing,  and  yet,  if  persisted  in,  very  often  gives 
an  evacuation.  The  breakfast  should  contain  honey,  milk-sugar 
or  levulose,  some  plum,  fig,  or  prune  preserves,  and  Graham 
bread.  Twice  daily,  a  glass  of  buttermilk  or  kefyr  may  be  admin- 
istered, if  agreeable  to  the  patient.  Where  the  constipation  resists 
this  diet  at  the  beginning,  a  trial  for  the  first  week  should  be  made 
with  large  colon  irrigations,  with  one  liter  of  normal  salt  solution, 
introduced  in  the  knee-elbow  position.  Fleiner's  enemata  of  250  c.c. 
(^  pint)  of  pure  olive  oil  are  more  lasting  in  their  effects,  one  enema 
sometimes  keeping  the  bowels  regular  for  a  week.  When  diarrhea 
is  present  large  irrigations  of  warm  water,  by  removing  ferment- 
ing and  putrefactive  colon  contents,  frequently  cure  it  without 
other  medication.  But  strict  dieting  for  a  few  days  is  always  ad- 
visable in  exhaustive  diarrheas,  as  it  shortens  the  attack.  In  diar- 
rheas, as  well  as  in  constipation,  the  state  of  the  gastric  secretion 
must  be  regarded,  and  HCl  or  alkalies  must  be  supplied,  as  the 
case  may  be.  Excess  of  HCl  secretion  may  provoke  diarrhea  by 
causing  carbohydrate  indigestion.  A  diet  of  Pasteurized  milk  and 
some  stimulant,  as  brandy,  and,  perhaps,  albumen  water  for  forty- 
eight  hours,  to  the  exclusion  of  everything  else,  is  most  effective. 
Soup  made  of  bouillon  and  thickened  with  wheat-flour  toasted 
brown  in  hot  butter,  is  quite  binding.  "  Eichelcacao,"  a  palatable 
German  preparation  of  chocolate,  can  be  recommended  for  its 
constipating  effect,  as  it  contains  much  tannin. 


446  CHRONIC    GASTRITIS. 

For  special  full  diet  lists  and  further  dietetic  directions  con- 
cerning this  disease,  as  well  as  other  recipes,  we  refer  to  the  section 
especially  devoted  to  this  subject, — the  comprehensive  chapter  on 
Dietetics  (pp.  223-226). 

As  Oilman  Thompson  points  out,  there  are  some  persons  in 
whom  the  digestion  of  salt  and  smoked  meats  seems  to  be  more 
easily  accomplished  than  that  of  prepared  fresh  meat.  Niemeyer 
offers  the  explanation  that  these  preparations  are  less  likely  to  de- 
compose in  the  stomach.  We  agree  with  Boas  {loc.  cit.,  p.  21)  in  the 
observation  that  there  is  very  little  fermentation  and  formation  of 
organic  acids  in  chronic  gastritis.  After  carefully  observing  this 
point,  we  maintain  that  it  is  not  necessary  to  withhold  the  saccharine 
and  farinaceous  foods,  as  Oilman  Thompson  suggests  {loc.cit.,^).  508). 
On  the  contrary,  they  should  be  liberally  supplied,  as  amylolysis 
progresses  rapidly  in  stomachs  that  secrete  no  HCl,  and  test-meals 
do  not,  as  a  rule,  show  the  excess  of  organic  acids  asserted  by  von 
Leube,  Evvald,  and  Rosenheim. 

Balneological. — There  is  much  truth  in  what  Prof.  Ira  Remsen 
said  when  he  opined  that  the  effect  of  the  use  of  natural  or  mineral 
spring  waters  was  not  attributable  to  the  chemical  constituents  or 
salts  of  these  waters,  but  more  to  the  favorable  mode  of  life,  the 
better  diet,  the  greater  introduction  of  plain  water  into  organisms 
which  previously  received  very  little  of  it,  and,  lastly,  to  important 
psychic  influences.  To  these  may  be  added  the  perfect  rest,  com- 
fort, and  auxiliary  methods  of  treatment  employed  at  the  springs. 
Thousands  of  Americans  visit  the  Oerman,  Austrian,  and  French 
spas  annually,  when  they  might  have  almost  the  same  waters — 
and  sometimes  much  better  ones — in  their  own  country.*  Obser- 
vations are  very  numerous  on  the  treatment  of  chronic  gastritis 
by  mineral  waters,  but  are  rather  inexact  and  based  upon 
imperfect  histories,  as  many  cases  are  called  chronic  gastritis 
which,  in  fact,  do  not  deserve  the  name.  One  can  not  well 
judge  of  the  effect  of  the  waters  alone,  as  they  are  always  com- 
bined with  dieting.  The  systematic  drinking  of  alkaline  waters 
must  not  be  estimated  to  be  worth  more  than  that  of  a  poor 
substitute  for  lavage.  As  the  object  is  to  promote  the  solution 
and  evacuation  of  mucus,  all  waters  will  be  equally  service- 
able, even    ordinary  spring  or  hydrant  water.     The  salts  can  be 

*  In  extended  travels  through  our  Eastern  States,  we  have  seen  over  20  mineral 
springs  discharging  very  healthy — sometimes  carbonated — waters,  that  are  not  at  all 
known  except  to  people  living  in  the  immediate  vicinity. 


MINERAL    WATERS,    BATHS,    GYMNASTICS.  44/ 

added  to  imitate  the  real  composition  of  the  famous  springs,  and 
are  made  by  several  wholesale  manufacturers  of  effervescent  salts 
for  this  purpose,  so  that  the  poorer  patients  ma}'  have  the  effect  of 
mineral  springs  at  home. 

(For  the  effects  and  contraindications  of  mineral  waters  the 
reader  is  referred  to  the  section  on  Mineral  Springs.  The  composi- 
tion of  artificial  Carlsbad  salts  is  given  on  p.  323.) 

In  the  use  of  alkaline  chlorids  it  is  expected  to  stimulate  the 
secretion  of  HCl.  Hot  spring  waters  must  be  cooled  and  the  cold 
water  warmed;  and,  in  dilatation  and  atony,  the  patient  had  best 
abandon  the  use  of  water  in  this  manner  entirely. 

Baths. — x\s  in  chronic  gastritis  the  general  metabolic  processes 
are  much  depressed,  a  cold  sponge  bath  taken  before  breakfast 
Avill  gradually  make  the  dyspeptic  more  resistant  by  its  stimulation 
of  cellular  oxidation  and  its  hardening  effect.  Warm  baths  we 
advise,  for  purposes  of  cleanliness  only,  once  or  twice  a  Aveek. 

Gymnastics. — All  patients  with  chronic  gastritis  should  be  en- 
couraged to  take  moderate  exercise  :  walking,  bic}-cle  riding,  horse- 
back riding  ;  also  rowing  and  swimming.  A  pair  of  four-pound 
dumb-bells  for  men  and  two-pounders  for  women  should  be  used 
three  times  daily,  each  time  for  five  minutes,  with  three  minutes  of 
rest  intervening  between  the  five  minutes  of  exercise.  This  will 
make  fifteen  minutes  of  training,  and  should  be  done  before  dressing, 
in  the  under-garments,  immediately  after  the  cold  sponge  bath. 
Great  care  should  be  bestowed  upon  the  tonicity  of  the  abdominal 
muscles.  Loss  of  the  unconsciously  and  continuously  acting  tonus 
of  these  muscles  is  a  most  potent  factor  in  the  etiolog}-  of  dilata- 
tion, gastroptosis,  and  floating  kidney.  There  are,  of  course, 
other  causes ;  but,  even  if  the  attachments  of  an  organ  are 
loosened,  it  can  not  wander  far  from  its  normal  location  with  a 
vigorous,  unrelenting,  external  abdominal  wall.  Therefore,  all 
patients  subject  to  digestive  diseases,  except  ulcer  and  carcinoma, 
should  train  their  abdominal  muscles  and  keep  them  active.  San- 
dow's  directions  for  accomplishing  this,  as  described  in  his  book, 
are  excellent. 

Electricity. — The  faradic  and  galvanic  currents  are  useful  in  the 
treatment  of  chronic  gastritis.  The  former  may  be  used  as  general 
external  faradism,  which  is  one  variety  of  a  general  massage.  One 
pole,  in  shape  of  a  broad,  flat  electrode,  is  moved  slowly  up  and 
down  over  the  spinal  column,  while  the  other  is  moved  over  both 


448  CHRONIC    GASTRITIS. 

arms  and  limbs,  and  particularly  over  the  abdominal  muscles^ 
With  one  pole  over  the  spine,  and  the  other  over  the  epigastrium, 
the  current  appears  to  go  directly  through  the  stomach,  and  yet 
there  is  no  evidence  that  the  organ  does  contract.  In  this  case  it 
is  doubtful  whether, any  current  reaches  the  stomach  at  all.  The 
good  effects  observed  after  this  method  must  be  attributable  to  the 
abdominal  massage  and  the  psychic  influence.  For  the  intragastric 
application  of  both  the  faradic  and  galvanic  currents,  the  practical 
intragastric  electrode  of  Einhorn  is  possibly  the  most  convenient. 
The  secretion  of  gastric  juice  can  not  be  influenced  by  either  the 
faradic  or  galvanic  current,  nor  can  the  motility  be  enhanced  (J.  C. 
Hemmeter,  Nezu  York  Med.  Jo7irnal,  ]un&  22,  1895,  p.  769).  As  the 
currents  usually  employed  for  this  purpose  are  too  weak  to  effect 
a  contraction  of  the  muscularis,  Meltzer  [New  York  Med.  Journal, 
June  15,  1895)  holds  that  percutaneous  and  direct  faradization  of 
the  stomach  and  intestines  can  not  produce  any  contraction  of 
these  parts.  Max  ¥.\x\h.om  {Air hiv  f.  Verdmiungskranklieiten,  Bd.ii, 
S.  454),  in  his  recent  contributions  to  the  subject,  is  of  entirely 
opposite  opinion.  As  mentioned  in  the  theoretical  part  of  this 
work,  we  have  been  able  to  demonstrate  that  the  human  stomach 
can  be  made  to  contract  under  faradic  stimulation  by  introducing 
the  intragastric  bag  (which  terminates  in  an  electrode  near  the 
pylorus)  and  connecting  it  with  the  kymograph.  Some  of  the 
intragastric  bags  ended  in  two  brass  electric  end-knobs,  one  on  the 
cardia  and  one  on  the  pylorus.  However,  the  currents  required  to 
cause  gastric  contraction  were  so  strong  as  to  become  hazardous 
(see  part  i,  p.  60).  As  Ziemssen  ("  Electrizitat  i.  d.  Medizin,"  1887, 
p.  445)  has  emphasized,  it  is  not  necessary  to  effect  gastric  contrac- 
tion in  order  that  electricity  should  prove  beneficial.  In  fact,  it 
would  appear  that  a  neuro-metabolic  or  -trophic  effect  of  electricity 
is  becoming  more  and  more  understood,  so  that  the  faradic  and 
galvanic  current  should  be  employed,  both  externally  over  the 
spine  and  epigastrium,  and  internally  with  the  intragastric  electrode  ; 
not  because  of  any  undeniable  evidence  that  it  can  influence  secre- 
tion, motility  or  absorption,  but  because  of  the  general  uniformity 
of  opinion  among  experienced  clinicians,  that  chronic  gastritis  is 
undoubtedly  benefited  by  electrical  treatment.  Even  Goldschmidt 
{loc.  cit.),  whose  results  regarding  the  effect  of  the  faradic  and  gal- 
vanic currents  on  secretion  and  motility  are  entirely  negative, 
admits  that  these   are   useful  ag-ents  in   the  treatment,  even  bene- 


MEDICINAL    TREATMENT.  449 

fiting  stomach  diseases  depending  upon  organic  changes.  It  is 
evident  that  while  experimental  evidence  of  the  manner  in  which 
electricity  acts  on  the  stomach  is  very  necessary,  the  clinical 
approval  of  its  therapeutic  utility  is  more  important. 

Medicinal  Treatment. — Two  chemicals  seem  to  have  maintained 
their  reputation  as  being  able  to  benefit  the  disease ;  these  are  ar- 
gentic nitrate,  either  in  form  of  gastric  spray  (i  :  looo),  or  lavage 
(i  :  2000),  or  in  form  of  solution,  0.3  to  120  of  peppermint  water  ; 
of  this,  one  tablespoonful  three  times  daily,  on  an  empty  stomach. 
The  second  drug  is  bismuth  subnitrate,  recommended  by  Penzoldt 
{loc.  cit.),  Fleiner  {loc.  cit.),  and  Pick  [loc.  cit.)  in  large  doses,  4  to  6 
gm.,  in  wafers.  With  both  remedies  we  have  had  experience,  and 
prefer  the  latter  in  the  following  form,  together  with  bismuth  sub- 
gallate,  which  certainly  diminishes  the  amount  of  mucus  formed 
in  alcoholic  gastritis  : 

R.     Bismuth  subnitratis, 48  gm.  3  xij 

Bismuth  subgallatis, 16  gm.  giv.         M.' 

Fiant  chart.  No.   xxiv. 
SiG. — One  powder  in  a  wafer  four  times  daily. 

Unfortunately,  this  treatment  is  constipating,  and  must,  there- 
fore, be  combined  with  a  diet  promoting  evacuation  and  the  use 
of  Saratoga  Congress  water.  Argentic  nitrate  is  best  employed 
in  form  of  the  intragastric  spray,  or  in  the  lavage.  These  drugs 
are  permissible,  particularly  when  diet  and  massage  can  not  be 
properly  carried  out.  They  were  originally  suggested  for  the 
treatment  of  ulcer  ;  their  efficacy  in  some  cases  of  chronic  gastri- 
tis is,  however,  undoubted. 

TJie  Hygiene  of  the  Month. — The  frequent  association  of  stomati- 
tis, gingivitis,  and  glossitis  with  this  disease  make  it  all-important 
that  the  mouth  should  be  in  a  healthy  condition.  Dental  defects 
and  their  repairs  have  already  been  referred  to  ;  but,  in  addition, 
the  mouth  should  be  disinfected  after  each  meal.  After  removing 
the  food  debris  by  toothpick  and  brush,  one  of  the  following  anti- 
septic lotions  should  be  used  both  on  the  brush,  applied  to  the 
teeth  and  the  root  of  the  tongue,  and  as  a  mouth  wash  : 

R.      Acid,  thymol, 0.25  gr.  iv 

Acid,  benzoic, 3-°  gr.  xlv 

Tr.  eucalypt., 15 -O  f^iijss 

Alcohol, 100. o  f^iijss 

Ol.menth.  pip., 0,75  ITLxij.      M. 

SiG. — Pour  sufficient  into  %  of  a  glass  of  water  until  turbidity  results. 
If  much  decomposition  be  present  0.8  hydrarg.  bichlorid  corrosive  can  be  added. 


450  CHRONIC    GASTRITIS. 

K .      Spirit,  lavandul., 

Spirit.  myrciK, aa 50.0  f,:^xijss 

Tinct.   myrrh., 5.0  fjj 

Saccharin, I.o  gr.  xv 

Menthol, i.o  gr.  xv.        M. 

SiG. — One-half  to  one  teaspoonful  to  a  glass  of  water. 

Treatment  of  the  Symptoms. — This  is  of  subsidiary  importance  to 
systematic  treatment  by  diet,  hygiene,  and  lavage  ;  but,  in  cases 
that  have  progressed  too  far,  or  in  secondary  forms  that  are  incura- 
ble (albuminuria,  diabetes,  etc.),  a  special  therapy  for  symptoms 
may  be  indispensable. 

The  treatment  of  loss  of  appetite  w'h'xch  we  advocate  is  the  following : 
Lavage  with  chlorid  of  sodium,  oSS  to  the  quart  or  a  decinormal 
solution  of  HCl ;  fluid  extract  of  condurango  in  doses  of  5j ; 
tincture  or  elixir  of  gentian.  Lavage  with  quassia,  Colombo,  or 
calisaya  solutions  will  often  produce  appetite.  Orexin,  a  new 
stimulant  to  the  appetite  and  HCl  secretion  (first  recommended  by 
Penzoldt),  is  best  given  in  the  following  form  : 

K: .      Orexin  basic, 0.2,  grs.  iijss. 

SiG. — !Make  one  wafer.     Take  one  wafer  in  a  cup  of  bouillon  half  an  hour  before 
meals,  t.  i.  d. 

Our  favorite  tonic  for  anorexia  in  chronic  gastritis  contains 
strychnin  and  hydrochloric  acid  in  the  following  proportion  for 
adults  : 

R .      Strych  sulphalis, •         .02  gr.  y^ 

Acid,  hydrochlorici  dilut. , 19-4  ^3^ 

Elixir  gentiana;, q.  s 180.  f^^'J-        ^^• 

SiG. — f^ss  in    "^V]  aquas  after  meals,  through  a  glass  tube. 
Fluid  extract  condurango  i'^  xij  may,  if  desired,  be  added. 

Some  old  gastritics  can  not  tolerate  so  much  hydrochloric  acid.  Then  the  dose  must 
be  reduced  to  five  drops,  t.  i.  d.  Always  precede  the  administration  of  HCl  by  a  test- 
meal  analysis,  so  as  to  find  out  the  degree  of  HCl  deficiency. 

Pyrosis  and  eructation  are  best  treated  with  magnesia  and  sodium 
bicarbonate,  according  to  the  principles  laid  down  in  the  manage- 
ment of  hyperacidity. 

Pain. — If  diet  and  lavage  do  not  relieve  this,  it  is  best  to  subject 
the  patient  to  a  rest  cure  of  eight  days,  with  hot  external  fomenta- 
tions to  epigastrium.  The  galvanic  current  has  been  a  very 
reliable  means  of  easing  pain  in  this  affection.  Opiates  and  other 
narcotics  must  be  avoided;  but,  in  the  very  rare  cases  where  this 
is  impossible,  they  should  be  given  by  the  rectum  or  (morphin) 
hypodermicall}-. 


TREATMENT    OF    SPECIAL    SYMPTOMS.  .     45 1 

The  same  treatment  applies  also  to  vomiting,  which  is,  as  a  rule, 
relieved  by  diet,  lavage,  small  pieces  of  ice,  or  champagne;  very 
rarely  does  it  become  so  distressing  a  symptom  as  to  require  a 
hypodermic  injection  of  morphin. 

Deficiency  of  gastric  juice  and  ferments  may  be  supplanted  by 
the  use  of  HCl  internally,  as  per  formula  stated  above.  If  HCl  is 
no  longer  tolerated,  it  is  well  to  convert  the  entire  gastric  chemistry 
into  an  alkaline  proteolysis  by  pancreatin  and  bicarbonate  of 
sodium.  In  long-standing  cases  the  mucosa  acquires  a  strange 
hypersensitiveness  to  all  acids,  which  points  the  way  to  this  plan  of 
treatment.  Reliable  pancreatin  and  sodium  bicarbonate,  of  each 
five  grs.,  are  recommended  by  Boas,  Witte,  Simon,  Schering,  and 
Penzoldt.  In  the  private  sanitarium,  we  have,  by  a  study  of  test- 
meals,  found  Reichmann's  preparation  of  fresh  ox  pancreas  an 
effective  digestant.  It  is  made  by  finely  mincing  one  ox  pancreas 
and  extracting  it  with  15  per  cent,  alcohol  or  brand}'  for  forty-eight 
hours,  and  straining.  The  dose  is  a  wineglassful  after  meals.  We 
very  rarely  found  it  necessary  to  give  pepsin;  for  if  HCl  is  still 
secreted,  pepsin  will  be  found  also,  and  if  HCl  be  absent,  al- 
though the  ferments  may  be  wanting,  it  is  expedient  to  give 
only  the  acid,  as  proteolysis  is  sufficiently  effective  in  the  intes- 
tine, and  the  effect  of  the  HCl  is  to  improve  the  appetite  and  pre- 
vent intestinal  fermentations.  It  would  require  enormous  quanti- 
ties of  pepsin  to  do  sufficient  proteolytic  work,  which  is  more  read- 
ily accomplished  by  pancreatin.  In  addition  to  this,  HCl  is  cheap 
and  pepsin  expensive,  so  that  it  is  impossible  to  have  patients 
continue  its  use  for  a  long  time. 

Motoj'  insitfficiency  \s,  iovtum.tQ\Y,  Si  very  rare  occurrence  in  the 
disease,  but,  if  present,  may  be  met  with  intragastric  use  of  lavage, 
electricity,  hydrotherap}',  massage,  and  strychnin.  This  will  be 
more  fully  treated  in  the  section  on  this  defect. 

Diarrliea  and  constipation  must  be  treated  by  diet  to  the  exclu- 
sion of  drugs ;  but  large  colon  enemata  are  valuable  and  permis- 
sible adjuncts  to  their  management. 

Psychic  depression  may,  according  to  the  most  prominent  under- 
lying cause,  require  one,  or  other,  or  several  of  the  methods  of 
treatment  mentioned.  But  regular  bowel  movements,  electricity, 
a  daily  tepid  or  cold  sponge  bath,  moderate  exercise,  massage,  surf 
baths,  and  climatic  changes  are  the  most  reliable  means  to  be 
employed.      Some  of  these    cases  will  not  recover  until  brought 


452  CHRONIC    GASTRITIS. 

to  a  properly  managed  institution  for  nervous  and  digestive 
sufferers. 

Advanced  Chemical  and  MecJianical  Defects. — When  the  glandular 
elements  have  been  completely  destroyed  as  a  result  of  hypertro- 
phic or  atrophic  metamorphosis  of  the  mucosa  and  degenerative 
processes  in  the  muscularis,  and  also  of  cirrhotic  contraction  of  the 
stomach,  secretion,  absorption,  and  motility  no  longer  exist. 
The  gravest  defect  now  is  the  loss  of  motility.  For,  in  the  total 
absence  of  all  gastric  digestion,  no  food  except  a  small  fraction  of 
the  carbohydrates  (ptyalin)  enters  into  solution.  The  ingesta  are 
not  reduced  sufficiently  in  size  because  there  is  no  churning  peri- 
stalsis and  no  secretion  ;  they  are  not  squeezed  out  into  the  duo- 
denum, because  the  propelling  peristalsis  is  missing.  Now,  although 
there  is  no  stenosis  of  the  pylorus  from  cicatricial  contraction  or 
neoplasm,  nor  even  a  pyloric  hyperplasia,  under  these  conditions 
there  is  what  we  may  term  a  "  relative  pyloric  stenosis  ";  that  is,  the 
pylorus  is  relatively  too  small  and  peristalsis  too  defective  for  the 
passage  of  the  insufficiently  macerated  ingesta.  This  combination 
of  things  may  occur  in  the  last  stages  of  chronic  gastritis  accom- 
panied by  the  clinical  aspects  of  progressive  anemia,  due  to  in- 
evitable malnutrition,  and  may  simulate  carcinoma. 

The  intestine,  although  it  may  be  healthy,  can  not  supplant  the 
absent  digestion  of  the  stomach  by  its  vicarious  action,  since  it  gets 
no  chance  to  do  so,  the  gastric  contents  fermenting,  and  eventually 
being  expelled  by  emesis,  rather  than  propelled  into  the  duodenum. 
This  state  should  be  treated  exactly  as  if  there  were  a  real  pyloric 
stenosis,  namely,  by  operation, — either  by  gastro-enterostomy  or  by 
dilatation  of  the  pylorus  ;  or,  if  an  excessive  atonic  gastrectasia 
with  immense  enlargement  of  the  stomach  and  normal  pylorus  be 
present,  by  gastroplication  (Bircher).  So  far,  it  appears  that  gastro- 
enterostomy has  been  done  but  once  under  these  conditions  for 
typical  gastric  atrophy  (Westphalen,  Petershirger  med.  Wochenschr., 
1890,  37,  38)  occurring  in  a  tuberculous  patient.  As  the  expelling 
force  of  the  peristalsis  is  much  reduced,  gastro-enterostomy  will 
probably  be  preferable  to  dilatation  of  the  pylorus.  The  indications 
for  surgical  operations  upon  the  stomach  have  been  separately  con- 
sidered (pp.  336-358).  They  are,  at  the  present  time,  more  clearly 
and  precisely  defined  for  cases  of  pyloric  stenosis  from  cicatrices  or 
neoplasms  than  for  cases  of  motor  insufficiency  due  to  gastric 
atrophy.     We    have    seen  one  case  of  well-defined    motor    insuf- 


OPERATION    FOR    REDUCING    THE    SIZE    OF    THE    STOMACH.       453 

ficiency,  with  a  history  of  two  years  of  gastric  pain,  hematemesis 
with  tar-colored  stools,  even  hyperacidity  of  the  vomit,  where  the 
operation  revealed  a  normal  pylorus,  and  no  ulcer  cicatrix  could  be 
detected.  The  gastrectasia  was  considerable,  but  the  stenosis  was 
evident  only  when  the  stomach  was  filled,  i.e.,  by  kinking  off  the 
pyloric  exit  at  its  hepatic  attachment.  This  kinking  off  at  the  duo- 
denal juncture  by  stomachs  that  are  dilated  occuring  only  when  dis- 
tended with  food,  but  apparently  normal  in  size  when  empty,  has 
been  first  described  in  an  interesting  report  by  Broadbent  {Bi'it. 
Med.  Jour.,  vol.  ii,  1893,  p.  1 193).  We  have  advocated  the  operative 
removal  of  the  stenosis  in  the  following  cases  :  Dilatation  with 
motor  insufficiency  due  to  the  various  conditions  that  may  arise 
from  the  atrophic  and  hyperplastic  forms  of  chronic  gastritis  ;  in 
either  an  absolute  (hypertrophic)  or  a  relative  stenosis  of  the 
pylorus  with  complete  atrophy  of  the  glandular  layer  and  loss  of 
secretion,  provided  the  intestine  can  be  ascertained  to  function 
normally.  In  extreme  dilatations  with  no  absolute  stenosis  gastro- 
plication,  as  first  carried  out  in  this  country  by  Weir  (A^.  Y.  Med. 
Jour.,  LVi,  29),  is  an  available  procedure  after  medical  treatment  has 
failed.  Gastroplication  does  not  strike  at  or  remove  the  cause 
of  the  dilatation.  Weir  [loc.  cit.)  designates  the  operation  of  reduc- 
ing the  size  of  a  dilated  stomach  by  making  a  fold  or  plait  in  it  as 
"  gastrorrhaphy."  This  is  the  same  operation  that  was  originally 
designed  by  Bircher  (p.  349)  and  termed  by  him  "  gastroplication." 
Weir  has  used  the  term  "  gastrorrhaphy  "  in  a  new  sense — similarly 
as  the  term  "  perineorrhaphy  "  is  employed  to  designate  an  opera- 
tive reduction  in  the  size  of  the  perineum.  Originally  the  meaning 
of  "  gastrorrhaphy  "  was  an  operation  for  closure  of  the  wounds 
of  the  stomach  (p.  340). 

LITERATURE   ON  ACUTE   AND    CHRONIC   GASTRITIS. 
In  addition  to  the  text-books  of — 

DeBove  and  Renvond,  Eichhorst,  Niemeyer, 

Einhorn,  Ewald,  Orth, 

Fleiner,  Fleischer,  Oser, 

Martin,  Sidney,  Forster,  Penzoldt, 

Bamberger,  Henoch,  Pick, 

Birch-Hirschfeld,  Jiirgensen,  Riegel, 

Boas,  Kunze,  Rokitansky, 

Bouveret,  Lebert,  Rosenheim, 

Brinton,  Leo,  Striimpell, 

Cohnheim,  Leube,  Trousseau, 

Cruveilhier,  Liebermeister,  Wegele, 

Dujardin-Beaumetz,  Hayem,  Ziegler,  and  others. 
30 


454  CHRONIC    GASTRITIS. 

1.  Beaumont,  "Experiments  and  Observations  of  the  Gastric  Juice  and  the 
Physiology  of  Digestion,"  Combe's  edition,  1833. 

2.  J.  Boas,  "Ueber  Schwefelvvasserstoffbildung  bei  Magenkrankheiten," 
Centralblaitf.  klin.  Med.,  1895. 

3.  A.  Cahn,  "  Die  Verwendung  der  Peptone  als  Nahrungsmittel,"  Berlin, 
klin.  IVochenschr.,  1893. 

4.  Charies,  "On  a  Case  of  Cirrhosis,  or  Fibroid  Infiltration  of  the  Stomach," 
Dublin  Journal  of  Med.  Science,  1878. 

5.  Curschmann,  "  Sitzung  des  Aerztlichen  Vereins  zu  Hamburg  vom  19. 
Mai,  1885,"  Deutsche  med.  Wochenschr.,  1885. 

6.  Deininger,  "  Zwei  Falle  von  idiopathischer  Gastritis  phlegmonosa," 
Deuhches  Archiv  filr  klin.  Med.,  xxill. 

7.  Ebstein,  "Ueber  die  Verjinderungen,  welche  die  Magenschleimhaut 
durch  Einverleibung  von  Alcohol  und  Phosphor  erleidet,"  Virchows  Arch., 
Bd.  LV. 

8.  Eisenlohr,  "  Ueber  primare  Atrophie  der  Magen-  und  Darmschleimhaut 
und  deren  Beziehung  zu  schwerer  Anamie  und  Riickenmarkserkrankungen," 
Deutsche  nied.  Wochenschr.,  1892. 

9.  Ewald,  "  Zur  Diagnose  und  Therapie  der  Magenkrankheiten,"  Berlin, 
klin.  Wochefischr.,  1886. 

10.  Fenwick,  Lecture  on  "Atrophy  of  the  Stomach,"  Lancet,  1877. 

11.  Fenwick,  "  On  Atrophy  of  the  Stomach,"  London,  1880. 

12.  Fenwick,  "Ueber  den  Zusammenhang  einiger  krankhafter  Ziistande 
des  Magens  mit  anderen  Organerkrankungen,  Virchow's  Archiv,  Bd.  cviii. 

13.  Fleiner,  "  Erfahrungen  iiber  die  Therapie  der  Magenkrankheiten," 
Volkjnan?t's  Samtnlung  klinischer  Vortrdge,  Nr.  103,  1894. 

14.  Fleiner,  "  Ueber  die  Behandlung  der  Constipation,  etc.,  mit  grossen 
Oelklystieren,"  Berlin,  klin.  Wochenschr.,  1893,  Nr.  3  u,  4. 

15.  Gerhardt,  "  Magenkatarrh  durch  lebende  Dipterenlarven,"  Jenaer  med. 
Zeitschr.,  iii. 

16.  Glax,  "  Die  Magenentziindung,"  Deutsche  med.  Zeitung,  1894. 

17.  Gluzinski,  "Ueber  das  Verhalten  des  Magensaftes  in  fieberhaften 
Krankheiten,"  Deutsches  Arch.f.  klinische  Med.,  Bd.  xlii. 

18.  Hanot  et  Gombault,  "  Etude  sur  la  Gastrite  chronique  avec  sclerose 
sous-muqueuse  hypertrophique  et  retroperitonite  calleuse,"  Arch,  de  Physi- 
ologie,  1882,  IX. 

19.  E.  Harnack,  "  Ueber  die  Verschiedenheit  gewisser  Aetzwirkungen 
auf  lebendes  und  todtes  Magengewebe,"  Berlin,  klin.  Wochenschrift,  1892. 

20.  Hayem,  "  Sur  I'anatomie  pathologique  de  la  gastrite  parenchymateuse 
hyperpeptique,"  Paris,  1893. 

21.  Henne,  "  Experimentelle  Beitrage  zur  Therapie  der  Magenkrankheiten," 
Deutsche  Zeitschr./.  klin.  Med.,  xix.  Supplement. 

22.  Honigmann,  "  Epikritische  Bemerkungen  zur  Deutung  des  Salzsaurebe- 
fundes  im  Mageninhalt,"  Berl.  klin.  Wochenschr.,  1893. 

23.  Honigmann,  "  Ueber  einige  wesentliche  Punkte  aus  der  Diatetik  fiir 
Magenkranke,"  Sep.-Abdr.  aus  der  Zeitschrift  filr  Krankenpflege,  1894. 

24.  Jaworski,  "  Zur  Diagnose  des  atrophischen  Magenkatarrhs,"  Verhand- 
lungen  des  Congresses  fiir  innere  Medicin,  Wiesbaden,  1888. 


LITERATURE    ON   ACUTE    AND    CHRONIC    GASTRITIS.  455 

25.  Immermann,  "  Ueber  die  Functionen  des  Magens  bei  Phthisis  tuber- 
culosa," Verhandlungen  des  Congresses  fiir  innere  Medicin,  Wiesbaden, 
1889. 

26.  V.  Kahlden,  "  Ueber  chronisch  sclerosirende  Gastritis,"  Centralblatt  f. 
klin.  Med.,  1887,  Nr.  16. 

27.  J.  Kaufmann,  "  Zvvei  Falle  geheilter  pernicioser  Anamie,"  etc.,  Berl. 
klin.  Wochenschrift,  1890. 

28.  Kuhieff,  "  Ueber  basische  Zersetzungsproducte  im  Magen-  und  Darm- 
inhalt,"  Berl.  klin.  Wochetischr.,  1891. 

29.  A.  Lesser,  "Atlas  der  gerichtlichen  Medicin,"  Berlin,  1884. 

30.  Lesser,  "  Cirrhosis  ventriculi."     Inaug.-Diss.     Berlin,  1876. 

31.  Leube,  "Ueber  die  Therapie  der  Magenkrankheiten,"  Volkinanns 
Sammlung  klin.  Vortrdge,'"  1873,  ■N^'-  62. 

32.  Leube,  "  Beitrage  zur  Diagnostik  der  Magenerkrankungen,"  Deutsches 
Arch.f.  klin.  Med.,   1883,  xxxiii. 

33.  Leube,  "  Ueber  eine  neue  Art  von  Fleischsolution  als  Nahrungs-  und 
Heilmittel  bei  Erkrankungen  des  Magens,"  Berl.  klin.  Wochenschr.,  1873. 

34.  Litten  und  Rosengart,  "  Ein  Fall  von  fast  voUigem  Erloschen  der  Secre- 
tion des  Magensaftes  (Atrophic  der  Magenschleimhaut),"  Zeiischr.  f.  klin. 
Med.,  XIV. 

35.  Manassein,  "  Chemische  Beitrage  zur  Fieberlehre,"  Virchow's  Arch., 
Bd.  LV. 

36.  B.  Mester,  "  Ueber  Magensaft  und  Darmfaulniss,"  Zeitschr.  fi'ir  klitt. 
Med.,  XXIV. 

37.  G.  Meyer,  "Zur  Kenntniss  der  sogenannten  Magenatrophie,"  Zeitschr. 
f.  klin.  Med.,  Bd.  xvi. 

38.  Mintz,  "  Ein  Fall  von  Gastritis  plegmonosa  diffusa  im  Verlaufe  eines 
Magenkrebses,"  Deutsches  Arch.  f.  klin.  Med.,  Bd.  xlix. 

39.  V.  Noorden,  "  Ueber  die  Ausnutzung  der  Nahrung  bei  Magenkrank- 
heiten," Zeitschriftf.  klitt.  Med..,  Bd.  xvii. 

40.  V.  Noorden,"  DerStoffwechsel  der  Magenkranken  und  seine  Anspriiche 
an  die  Therapie,"  Berliner  Klinik,  1893. 

41.  Nothnagel,  "  Cirrhotische  Verkleinerung  des  Magens  und  Schwund  der 
Labdriisen  unter  dem  klinischen  Bilde  der  perniciosen  Anamie,"  Deutsches 
Arch.f.  klin.  Med.,  xxiv. 

42.  Oppolzer,  "  Erfahrungen  iiber  die  Therapie  der  Magenkrankheiten," 
Zeitschr.  d.  k.  k.  Ges.  d.  Aerzte  zu  IVien,  Wien,  1857,  Xlil. 

43.  Penzoldt,"  Beitragzur  Lehre  von  der  menschlichen  Magenverdauung," 
Deutsches  Arch.f.  klin.  Med.,  Bd.  Li,  u.  Lili. 

44.  Penzoldt,"  Salzsaures  Orexin,  ein  echtes  Stomachicum,"  Therapeutische 
Monatshefte ,  Februar,   1890. 

45.  v.  Pfungen,  "Ueber  Atonie  des  Magens,"  Wien,  1887. 

46.  Pick  (Coblenz),  "  Die  Behandlung  des  chronischen  Magenkatarrhs  mit 
grossen  Bismuthdosen,"  Berl.  klin.  Wochenschr.,  1893. 

47.  Quincke,  "  Luftschlucken,"  Verhandlungen  des  VIL  Congresses  fiir 
innere  Medicin,"  Wiesbaden,  1889. 

48.  Quincke,  "  Ueber  perniciose  Anamie,"  Volkmann' s  Satmnhmg  klin. 
Vortrdge. 


456  CHRONIC    GASTRITIS. 

49.  Reichniann,  "  Ueber  die  Anwendung  der  Pancreaspraparate  beim  atro- 
phischen  Magenkatarrh,"  Deutsche  med.  Wochenschr.,  1889. 

50.  Riegel.  "Beitrage  zur  Pathologic  und  Diagnostik  der  Magenkrankheiten," 
Deiiisches  Archiv  f.  klin.  Med.,  xxxvi ;  Zeitschr.f.  klin.  Med.,  xi. 

51.  Riegel,  "Ueber  Diagnostik  und  Therapie  der  Magenkrankheiten," 
Volhnami  s  Sammbing  kliji.   Vortriige,  1886,  Nr.  289. 

52.  Rosenheim,  "  Ueber  atrophische  Processe  an  der  Magenschleimhaut  in 
ihrer  Beziehung  zum  Carcinom  und  als  selbststandige  Erkrankung,"  Berliti. 
klin.  Wochenschr.,  1888. 

53.  Rosenheim,  "Ueber  die  Magendusche,"  Therapeut.  Monatshefte,  1892. 

54.  Sachs,  "Die  Kenntniss  der  Magenschleimhaut  in  krankhaften  Zustan- 
den,"  A?'chivfur  exp.  Patholog.  u.  Pharm.,  xxil  u.  xxiv. 

55.  Schwalbe,  "Die  Gastritis  der  Phthisiker  vom  patholog.-anatomischen 
Standpunkte,"   Virchow  s  Arch.,  Bd.  cxvii. 

56.  Senator,  "Ueber  einen  Fall  von  Hydrothionanamie  und  iiber  Selbst- 
infection  durch  abnorme  Verdauungsvorgange,"  Berlin,  klin.  Wochefischrifi, 
1868. 

57.  Stintzing,  "Zur  Structur  der  erkrankten  Magenschleimhaut,  Miinchener 
med.  Wochenschrift,  1889,  Nr.  48. 

58.  Tawitzki,  "Ueber  den  Einfluss  der  Bitterstoffe  auf  die  Mengen  derSalz- 
saure  im  Magensaft  bei  gewissen  Formen  von  Magen-  und  Darmkatarrhen," 
Deutsches  Arch.f.  klifi.  Med.,  Bd.  XLViii. 

59.  Uffelmann,  "  Beobachtungen  und  Untersuchungen  an  einem  gastroto- 
mirten  fiebernden  Knaben,"  Deutsches  Arch.f.  klin.  Med.,  xx,  1877. 

60.  Wasbutzki,  "  Ueber  den  Einfluss  von  Magengahrungen  auf  die  Faulniss- 
vorgange  im  Darmkanal,"  Arch,  fi'ir  exp.  Patholog.,  etc.,  Bd.  xxvi. 

61.  Werther,  "Ueber  den  therapeutischen  Werlh  der  Pepsinweine,"  Berlin, 
klin.  Wochenschrift,  1892. 

62.  Wolff-Gothenberg,  "  Beitrage  zur  Kenntniss  der  Einwirkung  verschie- 
dener  Genuss-  und  Arzneimittel  auf  den  menschlichen  Md^gen^dSt,"  Zeitschr.f. 
klin.  Med.,  Bd.  xvi. 

63.  Losch,  "Ueber  die  nach  Einwirkung  abnormer  Reize  auf  die  Magen- 
schleimhaut auftretenden  pathologisch-anatomischen  Veranderungen,"  Allgem. 

Wiener  med.  Zeitung,  1881,  No.  50. 

64.  P.  Griitzner,  "  Neue  Untersuchungen  iiber  Bildung  and  Ausscheidung 
des  Pepsins  im  Magen,"  Breslau,  1875. 

65.  Edinger,  "  Zur  Kenntniss  der  Driisenzellen  des  Magens,  besonders  beim 
Menschen,"  AT.  Schulizer  s  Archiv,  Bd.  xvii,  S.  209. 

66.  C.  Kupffer,  "  Epithel  und  Driisen  des  menschl.  Magens,"  Miinchen,  1883. 

67.  Virchow,  R.,  "  Der  Zustand  des  Magens  bei  Phosphorvergiftung,  Vir- 
choTvs  Archiv,  Bd.  xxxi,  S.  388. 

68.  Klebs,  "  Handbuch  d.  patholog.  Anatomie,"  1868,  S.  174. 

69.  Marfan,  "  Troubles  et  lesions  gastriques  dans  la  phthisie  pulmonaire," 
Paris,  i88q. 

70.  ^\\TL\.z\-ng,  Munchener  7ned.  Wochefischr.,  1890. 

71.  Widal,  Le  Bulletin  Medicate,  1896,  Nos.  59,  78,  61,  64,  83,  and  1897, 
No.  4. 

72.  Ktihnau,  Berl.  klin.  Wochenschr.,  1897,  No.  19. 


LITERATURE    ON    PHLEGMONOUS    GASTRITIS.  45/ 

COMPLETE  BIBLIOGRAPHY  OF  PHLEGMONOUS  GASTRITIS. 

A. 

1.  Andral,  G.,  "  Maladies  de  I'abdomen,"  Cliniqiie  Medicale,  1839, 
tome  II. 

2.  Auvray,  "  Etude  sur  la  Gastrite  phlegmoneuse,"  These  de  Paris,  1866. 

3.  Asverus,  "  Ein  Fall  von  Gastritis  phlegmonosa,"  y,?;mW(:/z<?  Zeitschr.  f. 
med.  Natur.,  Jena,  1866,  Bd.  11,  S.  476-482. 

4.  Ackermann,  "  Ein  Fall  von  phlegmonoser  Gastritis  mit  Thrombose  zahl- 
reicher  Magenvenen  und  embolischen  Heerden  in  der  Leber  und  in  den 
Lungen,"  Virchoivs  Archiv,  1869,  Bd.  xlv,  S.  39. 

5.  Albers,  Rheinisch-Westph.  med.  Correspondetizblatt,  1884,  No.  5,  re- 
ported by  Tilhnanti's  Arch.f.  klin.  Chir.,  Berlin,  1882,  Bd.  xxvii,  S.  155. 

B. 

6.  Beckler,  "  Ein  Fall  von  idiopathischer  phlegmonoser  Gastritis,"  Bayer. 
Aerztl.  /«/.-5/.,-Munchen,  1880,  Bd.  xxvii.  No.  37,  S.  403. 

7.  Brinton,  "  Diseases  of  the  Stomach." 

8.  Bonetus,  "  Sepulchretum  sive  Anatomia  Practica,"  Lib.  ill,  Geneva, 
1700. 

9.  Bamberger,  "Henoch's  Klinik  der  Unterleibskrankheiten,"  Berlin,  1855, 
Bd.  II,  S.  196. 

10.  Belfrage  and  Bedenius,  Schinidfs  Jahrb.,  Leipzig,  1872,  Bd.  CLiv, 
S.  298. 

11.  Bianchetti,  "  Sopra  un  laso  bi  Gastrite  Flemonosa,"  Gaz.  Med.  Ital., 
Prov.  Venete,  Padova,  1875,  vol.  xvii,  p.  217. 

12.  Bouveret,  "  Traite  de  pathologia  Generale,"  1895,  tome  i,  p.  781. 

13.  Bret  and  Paviot,  Rev.  de  Med.,  Paris,  May  10,  1894,  p.  384. 

14.  Budd,  "  Organic  and  Functional  Diseases  of  the  Stomach,"  1855. 

C. 

15.  Cruveilhier,  vide  Raynaud,  p.  526. 

16.  Chvostek,  "  Zwei  Falle  von  primarer  dififuser  phlegmonoser  Gastritis," 
Wien.  med.  Presse,  1877,  Nos.  22,  29,  Bd.  xvii,  S.  693. 

17.  Chvostek,  "Ein  weiterer  Beitrag  zur  primaren  dififusen  phlegmonosen 
Gastritis,"  Wien.  med.  Bl,  1881,  No.  28,  Bd.  iv,  S.  831,  861,  891,  924,  962. 

18.  Caudmont,  Bull.  Sec.  Anat.  de  Paris,  1848,  tome  xxxiii,  p.  273. 

19.  Cahn,  "  Gastritis  diphtheritica  mit  acuter  gelber  Leberatrophie," 
Deulsches  Arch.f.  klin.  Med.,  Leipzig,  1883,  Bd.  xxxiv,  S.  113-121. 

20.  Callow,  vide  Auvray  {loc.  ciL). 

20  a.  Cornil,  vide  Auvray  {loc.  cit.,  p.  20). 

D. 

21.  Deininger,  "Zwei  Falle  von  idiopathischer  Gastritis  phlegmonosa," 
Deutsches  Arch.f.  klin.  Med.,  Leipzig,  1878-1879,  Bd.  xxii,  S.  624-632. 

22.  Dirner,  "Gastritis  Phlegmonosa,"  Orbosi  hetila.,  Budapest,  1881,  vol. 
XXV,  p.  793. 

23.  Dumesnil,  vide  Auvray  {loc.  cit.). 


458  CHRONIC    GASTRITIS. 

E. 

24.  Ewald,  "  Lectures  on   Diseases  of  the  Stomach,"  N.  Sydenham  Soc. 
Trans.,  1892,  p.  504.     (From  CUnic  of  Frerichs.) 


25.  Fagge,  "  A  Case  of  Diffused  Suppurative  Inflammation  of  the  Stomach," 
Trans.  Path.  Soc,  London,  1874-75,  vol.  xxvi,  p.  81. 

26.  Frjinkel,  "  Ueber  einen  Fall  von  Gastritis  acuta  emphysematosa, 
wahrscheinlich  mykotischen  Ursprungs,"  Virchow  s  Archiv,  1889,  Bd.  CXVIII, 
S.  526. 

27.  Feroci,  Ann.  tmiv.  di  vied,  e  chir.,  Milano,  1873. 

28.  Flint,  quoted  by  Reinking  {loc.  cit.),  S.  16,  Phiia.  Med.  Times,  Aug.  8, 
1878. 

29.  Ferraresi,  "Sulla  Gastrite  Flemmonoso,"  yi///  Accad.  med.  di  Roma, 
1887,  series  xi,  vol.  cxi,  p.  267. 

30.  Fontain,  "Gastrite  Phlegmoneuse,"  Bull,  et  mein.  Soc.  med.  d.  hop  de 
Paris,  1866,  tome  xi,  p.  131. 

G. 

31.  Glax,  "  Ueber  Gastritis  phlegmonosa,"  Berl.  klin.  Wochenschr.,  1879, 
Bd.  XVI,  S.  565. 

32.  Glax,  "  Die  Magenentziindung,"  Deutsche  med.  Zig.,  Berlin,  1884, 
No.  3. 

33.  Guyot,  "Gastrite  Phlegmoneuse,"  Union  med.,  Paris,  1865,  N.  S.,  tome 
XXVII,  pp.  184-185. 

34.  Garel,  cited  by  Reinking,  1879  (^'''^-  "^O.  S.  17,  Lyonjned.,  Oct.,  1871. 

35.  Glaser,  "  Zwei  Falle  von  Gastritis  phlegmonosa  idiopathica,"  Berl.  klin. 
Wochenschr.,  1883,  Bd.  xx,  S.  790.     (Two  cases.) 

36.  Gaudy,  "  Observation  de  Gastrite  Phlegmoneuse,  Arch.  Med.  Beige, 
Bruxelles,  1863,  tome  xxxi,  pp.  459-464. 

37.  Gilbert  and  Dominici,  Med.  Jour.,  New  York,  May,  1894;  cited  from 
Leith's  article  {loc.  cit.). 

H. 

38.  Heyfelder,  "  Sanitatsbericht  liber  das  Fiirstenthum  HohenzoUern  Sig- 
maringen  wahrend  des  Jahres  1836,"  Schnidfs  Jahrb.,  Leipzig,  1837,  Bd.  xvi, 
S.  192. 

39.  Herzog,  Kaspar  s  Wochenschr.,  1839,  S.  813  ;  quoted  by  Reinking  {Joe. 
cit.,  S.  11). 

40.  Hun,  "  Idiopathic  Phlegmonous  Inflammation  of  the  Submucous  Cellu- 
lar Tissue  of  the  Stomach,"  N.  V.  Aled.  /our.,  186S,  vol.  viii,  p.  18. 

41.  Habershon,  "Case  of  Suppuration  in  the  Coats  of  the  Stomach," 
Guy's  Hosp.  Rep.,  London,  1855,  p.  115. 


42.  Krause  (same  case  as  No.  45),  "  Ueber  submucose  phlegmonose  eitrige 
Magenentziindung,"  Berlin,  1872,  Inaug.-Diss.,  Kiel,  1874- 


LITERATURE    ON    PHLEGMONOUS    GASTRITIS.  459 

43.  Klebs,  "  Ueber  infectiose  Magenaffectionen,"  Allg.  IVien.  lued.  Ztg., 
1881,  Nos.  29,  30,  31,  32,  34,  35. 

44.  Klaus,  "  Beitrag  zur  Kenntniss  d.  Magenkrankheiten,"  Inaug.-Diss., 
Erlangen,  1857. 

45.  Krause  (same  case  as  No.  42),  "  Ueber  submucose  phlegmonose  eitrige 
Magenentziindung,"  Inaug.-Diss.,  Kiel,  1874. 

46.  Kelynack,  "A  Case  of  Diffuse  Phlegmonous  Gastritis,"  Lancet,  London, 
1896,  March  14th. 

47.  Krabbe,  Tidskr.  f.  K^'/.,  Kjobenhaven,  1872;  a.r\<\  Deutsche  Zeitsckr.f. 
Tkiermedicm ,  Leipzig,  Bd.  I. 

48.  Kurschmann,  "  Magenabscess,"  Wien.ined.  Wochenschr.,  1880,  No.  14. 

L. 

49.  Leube,  "  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine,"  1877, 
vol.  VII,  p.  154. 

50.  Lewandpwski,  "  Zur  Casuistik  der  idiopathischen  Gastritis  phlegmo- 
nosa,"  Berl.  klin.  Wochenschr.,  1879,  ^^'  ^^^^  S.  568. 

51.  Lowenstein,  "  Ueber  Gastritis  phlegmonosa,"  Inaug.-Diss.,  Kiel,  1874. 

52.  Loomis,  Med.  Rec,  N.  Y.,  Feb.  15,  1869. 

53.  Lindemann,  "  Fall  von  Gastritis  phlegmonosa  diffusa,"  yJ/?7«r/i.  med. 
Wochenschr.,  1887,  No.  25. 

54.  Lieutaud,  "  Historia  Anatomica-medica "  (includes  observations  by 
Riolanus,  Baunimus,  and  others),  1767,  tome  i,  p.  2. 

55.  Lewin,  "  Zur  Casuistik  der  Gastritis  phlegmonosa  idiopathica,"  Berl. 
klin.  Wochenschr.,  1884,  Bd.  xxi,  S.  83. 

56.  Leith,  "  Phlegmonous  Gastritis  ;  Its  Pathology,  Etiology,  Symptoms,  and 
Treatment,"  Edmhtirgh  Hospital  Reports,  vol.  iv,  pp.  51-114. 

56  a.  Lasege,  vide  Auvray  (Joe.  cit.). 

M. 

57.  Manoury,  "  Infiltration  Purulente  Puerperale  de  I'Estomac,"  Bull.  Soc. 
Anat.de  Paris,  1842,  tome  xvii,  p.  175. 

58.  Mayor,  "  Absces  Sous-muquex  de  I'Estomac,"  Bull.  Soc.  Anat.  de  Paris, 
1840,  tome  XVII,  p.  298. 

59.  Mazet,  "  Phlegmon.  Diffuse  de  I'Estomac,"  Bull.  Soc.  Anat.  de  Paris, 
1840,  tome  XV,  p.  174. 

60.  Macleod,  "  Suppurative  Gastritis,"  Lancet,  London,  1887,  vol.  xi, 
p.  1 166. 

61.  Martin,  "  Diseases  of  the  Stomach,"  1895,  p.  277. 

62.  Mintz,  "  Ein  Fall  von  Gastritis  phlegmonosa  diffusa  im  Verlaufe  eines 
Magenkrebses,"  Deutsches  Arch.  f.  klin.  Med.,  Leipzig,  1892,  Bd.  XLIX, 
S.  487. 

63.  Mascaral,  Bull.  Soc.  Anat.  de  Paris,  1830,  tome  xv,  p.  176. 

64.  Morel,  "  Gastrite  Phlegmoneuse,"  Bull.  Soc.  Anat.de  Paris,  1865. 

65.  Malmsten  and  Key,  "  Fall  af  Flegmonos  Gastritis.  Hygiea,"  Stockholm, 
1 87 1,  p.  69. 

66.  Meyer,  St.  Petersb.  med.  Wochenschr.,  1892,  No.  40. 


460  CHRONIC    GASTRITIS. 

N. 

67.  Nasse  and  Orth,  Virchow's  Archiv,  Bd.  civ,  S.  584. 

68.  Nielsen,  "  Bradsot   hos  Faaret  (Gastromycosis   ovis),"    Tidskr.  f.  Vet., 
Kjobenhaven,  1887,  pp.  1-21. 

O. 

69.  Oser,  Realencyclopadie:  "  Magenentzundung,"  1887,  Bd.  xi,  S.  412. 

70.  Odmansson,  "Gastritis  Phlegmonosa    Diffusa,"   Forh.  v.    Svens.  Lak. 
Sallsk.  5ia:;«;;za«/&,  Stockholm,  1865,  p.  265. 

P. 

71.  Page,  "  A  Case  of  Gastrostomy,  fatal  on  the  twenty-third  day  from  acute 
Parenchymatous  Gastritis,"  Lancet,  London,  1883,  vol.  11,  p.  53. 

72.  Petersen,    "  Ein    Fall   von   Gastritis   phlegmonosa,"    St.   Petersb.  jned. 
Wochenschr.,  1879,  B^.  iv,  S.288. 

73.  Pilliet,  Bull.  Soc.  Anat.de  Par-is,  1893,  No.  22. 

R. 

74.  Raynaud,  "  Da  1' Infiltration  Purulence  de  I'Estomac,"  Bull.  Soc.  Anat. 
de  Paris,  1861,  tome  vi,  pp.  62-93. 

75.  Robel,  P.,  Opera,  1656. 

76.  Reinking,  "  Beitrag  zur  Kenntniss  der  phlegmonosen  Gastritis,"  Inaug.- 
Diss.,  Kiel,  1890,  S.  26. 

Tl.  Rakowak,  Duchek's  Klinik ;    Wien  med.  Presse,  1873,  No.  25. 

S. 

78.  Sand,  "  Dissertatio  de  raro  Ventriculi  Abscessu  Regiomont,"  1701. 

79.  Silcock,    "  Stomach  Exhibiting  the  Condition  known  as   Phlegmonous 
Gastritis,"  Trans.  Path.  Soc,  London,  1882-83,  vol.  xxxiv,  p.  90. 

80.  Sebillon,  "  De  la  Gastrite  phlegmonosa,"  These  de  Paris,  1885. 

81.  Smith,  Med.Rec,  New  York, Oct.  12,  1889. 

82.  Strieker    und    Kooslakoff,     "  Experimente    iiber    Entziindungen    des 
Magens,"  Sitzungsb.  d.  k.  Akad.  d.  Wissensch.,  Wien,  1866,  Bd.  Liii. 

83.  Smirnow,  "  Ueber  Gastritis  membranacea  und  diphtheritica,"  Virchow's 
Archiv,  1889,  Bd.  cxiii,  S.  333. 

84.  Sestier,  "Absces  Metastatique  des  Parois  de  I'Estomac,"  Bull.  Soc.  Anat. 
de  Paris,  1883,  tome  viii,  p.  130. 

85.  Stewart,  "A   Case   of  Gastritis  Phlegmonosa,  with  Inflammation    and 
Gangrene  of  the  Gall-bladder,"  Edin.  Med.  Jour.,  1868,  N.  S.,  vol.  xii,  pp. 

732-735- 

T 

86.  Treuberg,    "  Primary    Phlegmonous    Inflammation    of    the   Stomach," 
Vrach.  St.  Petersb.,  1883,  vol.  lv,  p.  355. 

87.  Thungel,  "Ein  Fall  von  Vereiterung  des  submucosen  Zellgewebes  des 
Magens,"  Virchows  Archiv,  1865,  Bd.  xxxiii,  S.  406-408. 

88.  Testi,  Alberico,  "Un  raro  caso  di  ascesso  dello  stomaco,"  Annal  univ. 
di  med.  e  chir.,  Milano,  Dec,  1883,  P-  523-547. 

88  a,  Thoman,  Allgern.  Wiener  Zeitujtg,  1891,  No.  10. 


LITERATURE    ON    PHLEGMONOUS    GASTRITIS,  46 1 

V. 

89.  Vonvaltner,  Eph.  Nat.  cur.,  Dec.  3,  Obs.  142. 

90.  A^arandaeus,  "  Tractatus  de  ]\Iorbis  Ventriculi,"  1620. 

W. 

91.  Wallmann,   Wie7ter  med.  Wochenschr.,  1857,  Bd.  xill,  S.  733. 

92.  Whipham,  "Remarks  on  a  Case  of  Phlegmonous  Gastritis,"  Brit.  Med. 
Jo2ir.,  London,  1884,  vol.  I,  p.  896. 

93.  Wilks  and  Mokon,  "Pathological  Anatomy,"  3d  edition,  1889,  p.  399. 

Z. 

94.  Ziegler,  "  Pathologische  Anatomie,"  Bd.  11,  S.  513. 


CHAPTER  III. 
ULCER  OF  THE  STOMACH. 

Ulcus  Ventricidi,  Peptiaun,  Rotuiuhnn,  Perforans,  Rodcns, 
Corrosh'wn,  e  Digestione. 

Ulcer  of  the  stomach  is  a  loss  of  substance  of  the  gastric 
mucosa,  characterized  by  very  httle  tendency  toward  healing,  but 
rather  by  destructive  progression  both  in  a  longitudinal  direction, 
i.  e.,  in  a  line  with  the  surface,  and  toward  the  depth  of  the 
mucosa.  It  may  occur  in  two  forms,  (i)  the  acute  and  (2)  the 
chronic.  The  acute  form  extends  so  rapidly  from  the  mucosa 
toward  the  peritoneum,  with  such  small  lateral  involvement,  that 
Rokitansky's  original  comparison,  "  as  if  the  ulcer  were  cut  out 
with  a  punch,"  has  become  the  classical  expression  of  the  text- 
books. In  the  chronic  form  the  destructive  process  is  not  so  rapid  ; 
it  extends  more  laterally,  producing  a  terraced  or  shelving  appear- 
ance of  the  edges  and  sides,  so  that  it  may  be  funnel-shaped. 
Perforation  into  an  artery,  vein,  or  into  the  peritoneal  cavity  occurs 
in  both  forms.  The  chronic  form  has  a  tendency  to  healing,  but 
in  so  doing  causes  cicatricial  contractions  and  deformity.  The 
acute  form  may  terminate  in  healing,  but  owing  to  its  limited  lateral 
extent,  the  small  cicatrix  rarely  causes  deformity.  It  is  very  prob- 
able that  the  acute  ulcers  have  a  different  etiology  (corrosives, 
toxic  action,  trauma  by  sharp,  hard  materials  in  the  food,  in  conjunc- 
tion with  other  factors  to  be  considered)  from  the  chronic  eroding 
type,  to  which  the  following  description  appertains  more  especially. 

Self-digestion  of  the  Stomach  (Gastromalacia). — If  an  animal 
be  killed  while  in  full  digestion,  the  stomach  may  undergo  self- 
digestion  after  death  if  the  body  is  kept  warm.  In  human  beings 
who  died  suddenly  while  the  gastric  digestion  was  at  its  height,  it 
was  found  at  the  autopsy  that  not  only  the  stomach  had  been 
digested,  but  also  the  spleen,  and  that  this  process  had  extended 
through  the  diaphragm  into  the  lungs.  The  question  naturally 
arises,  What  protects  the  stomach  from  autodigestion  from  its 
own    secretions    under    normal  conditions?      This   is   an  inquiry 

462 


EXPERIMENTAL    PRODUCTION    OF    GASTRIC    ULCERS.  463 

that  concerns  the  fundamental  properties  of  living  matter,  for  it 
includes  the  nondigestion  of  the  intestinal  tract  by  the  alkaline 
pancreatic  juice  and  succus  entericus,  the  same  property  as 
observed  in  the  digestive  tracts  of  invertebrates  and  even  in  the 
unicellular  organisms,  the  amebse  and  plasmodia  of  mycetozoa. 
For  instance,  Metschnikoff,  C.  Le  Dantec,  Greenwood,  Saunders, 
and  the  author  have  shown  that  a  secretion  is  formed  in  the 
digestive  vacuoles  of  these  unicellular  organisms  which  digests 
foreign  proteid  material,  but  not  the  living  substance  of  the  cell 
itself  (see  "  On  the  Role  of  Acid  in  the  Digestion  of  Certain 
Rhizopods,"  by  J.  C.  Hemmeter,  Philos.  D.,  etc.,  in  American  Na- 
turalist, August,  1896,  p.  619). 

The  following  explanations  have  been  offered  for  the  protection 
of  the  human  stomach  from  its  own  secretion  : 

1.  By  Hunter:  That  the  principle  of  life  in  living  things  pro- 
tected them  from  digestion.  Resorting  to  a  hypothetical  principle 
in  explanation  of  the  properties  of  living  matter,  can  not  be 
seriously  considered  in  the  science  of  biology. 

Moreover,  Bernard  succeeded  in  demonstrating  that  the  hind  leg 
of  a  frog,  introduced  into  a  dog's  stomach  through  a  fistula,  under- 
goes digestion.  This  will  also  happen  if  the  leg  be  placed  in  a 
vessel  containing  gastric  juice  at  the  proper  temperature. 

2.  Bernard  explained  the  exemption  of  the  normal  stomach 
from  autodigestion  by  assuming  a  protective  power  in  the  living 
epithelium,  which  he  thought  prevented  the  absorption  of  gastric 
juice. 

3.  Strieker  believed  that  the  mucus  formed  on  the  surface  of  the 
stomach  acts  as  a  protective  covering. 

4.  Pavy  ("  Guy's  Hospital  Reports,"  vol.  xiv,  1868)  held  that  the 
alkaline  blood  circulating  through  the  gastric  walls  saved  them 
from  digestion,  since  it  neutralized  the  acid  as  fast  as  it  was 
absorbed.  None  of  these  explanations  is  sufficient.  Bernard's 
suggestion  simply  shifts  the  problem  by  assuming  an  immunity  of 
the  living  epithelial  cells  without  attempting  to  explain  why  these 
are  not  digested.  The  coating  of  mucus  which  Strieker  believed 
to  be  a  protection  is  the  contrary ;  for  in  gastric  diseases  in  which 
there  is  excessive  formation  of  mucus,  autodigestion  is  more  fre- 
quently observed  than  in  normal  stomachs,  provided  HCl  is  secreted. 

Pavy's  theory  that  the  alkaline  reaction  of  the  gastric  circulation 
prohibits   self-digestion,  is  untenable,  because   under  these   condi- 


464  ULCER    OF    THE    STOMACH. 

tions  one  could  not  explain  why  the  pancreas  does  not  digest  itself, 
and  is  also  disproved  by  Samelson,  who  produced  a  neutral  reaction 
of  the  blood  by  gradual  introduction  of  acid,  and  then  poured  dilute 
HCl  into  the  animals'  stomachs  ;  but  even  then  no  autodigestion  was 
observed.  On  the  whole,  the  question  of  the  exemption  of  the 
stomach  from  self-digestion  remains  unanswered.  When  Hunter, 
over  one  hundred  years  ago  (1786),  referred  the  immunity  to  a  spe- 
cific property  of  the  living  cells,  "  the  vital  principle,"  he  gave  as 
good  an  explanation  as  any  given  up  to  date.  The  expression 
"vital  principle"  may  sound  mysterious  in  the  light  of  modern 
physiological  knowledge,  but  it  undoubtedly  implied  that  gastric 
immunity  from  self-digestion  was  due  to  physical  and  chemical 
forces  possessed  by  the  protoplasm  of  living  cells  and  which  are  not 
as  yet  understood.  In  the  latter  term  we  use  more  accurate  expres- 
sions, but  still  leave  the  whole  question  as  unexplained  as  Hunter. 

Elsasser  agreed  that  gastromalacia  was  always  a  cadaverous  pro- 
cess, and  was  supported  in  this  view  by  Virchow,  Foster,  Oppolzer, 
Bamberger,  and  others,  so  that  his  opinion  became  the  prevailing 
one.  A  contrary  view  was  held  by  Rokitansky,  who  represents 
the  belief  that  there  is  a  gastromalacia  that  occurs  intra  vitavi 
particularly  in  the  end  stages  of  grave  diseases  of  the  brain  and  its 
membranes  (basal  and  tuberculous  meningitis)  and  in  other  severe 
exhausting  affections.  The  occurrence  of  intravital  autodigestion 
was  proved  in  a  case  reported  both  by  W.  Mayer  and  Leube  from 
Ziemssen's  clinic,  and  also  by  numerous  animal  experiments. 

Results  of  animal  experiments  in  producing  secondary  injury 
and  consequent  self-digestion  of  the  stomach  are  the  following  : 
Schiff,  by  intersection  of  the  thalami  and  cerebral  peduncles,  pro- 
duced hemorrhagic  infiltrations,  partial  softenings,  erosions,  and 
even  ulcer  formation  in  the  gastric  mucosa,  and  interpreted  his 
results  as  consequences  of  neuroparalytic  hyperemia  caused  by 
injury  to  the  central  vasomotor  nerve-tracks  of  the  stomach. 
Ebstein  and  Brown-Sequard  obtained  identical  effects  after  circum- 
scribed destruction  of  the  anterior  corpora  quadrigemina.  Panum 
injected  an  emulsion  of  tiny  wax  globules  into  the  femoral  arteries 
of  dogs  and  effected  small  gastric  hemorrhagic  infarcts  and  ulcers. 
Cohnheim  injected  suspensions  of  plumbic  chromate  into  the 
stomach  circulation,  by  which  he  succeeded  in  blocking  only  the 
branches  of  the  mucosa  and  submucosa,  while  the  circulation  of 
the  muscularis  remained  free.     At  the  autopsy  he  discovered  large 


PLATE  VII. 


•r-     ri     r^  ". 


OJ 

-e^ 

'w^ 

o<^ 

o 

a 

<"-5 


o 

3 

>> 

CJ 

o 

<U 

a 

'^ 

O 

g 

> 

c 

> 

J3 

,. 

^ 

2 

<u 

zi 

S 

•n 

o 

— 

> 

ci 

_ 

— 

OJ 

5  ^ 


"5  M-c  o 

■c  2  4J 

in  "5    HJ  " 

.    5    O    cS  u, 


C  T-    o    rt    o  Jl 


u  E  ^ 
1— '  o  -=:  ■ 


P  s 


o  S  2  <u 


■■  ■  .2 


c.-ti-a      ^ 


<  o 


in.  o 

1) 


^  2-2;^ 


&  o  c  - 

:/;    E-  O    «J 


o  Sort's  3 

O  ~    O    O    1>  ' 

=   52   =   =:. 

-^    Cl,  -    Ij    o  i 

o  o  £  -S  ^  ' 


CIRCULATORY    AND    SECRETORY    ANOMALIES.  465 

ulcers  with  abruptly  descending  edges  and  clean  bases.  Koch  and 
Ewald  brought  about  gastric  hemorrhagic  infarcts  by  intersec- 
tion of  the  spinal  cord  (Schiff's  method),  and  after  this  introduced 
strong  solutions  of  hydrochloric  acid,  five  per  looo,  into  the 
stomach,  thereby  producing  penetrating  ulcerations.  After  severe 
traumatism, — for  example,  bruising  the  epigastric  region  with  a 
hammer, — and  after  thermic  irritation,  as  by  introducing  very  hot 
gruel,  Ritter  and  Decker  produced  ulcus  ventriculi.  Silbermann 
brought  on  gastric  ulcers  that  healed  with  difficulty,  by  causing 
hemoglobinemia  with  substances  that  dissolved  the  blood-corpus- 
cles. 

His  results  are  significant,  as  explaining  the  pathogenesis  of  gas- 
tric ulcer  after  extended  skin  burns  and  malaria.  This  is  to  a 
certain  extent  explained  by  the  investigations  of  Klebs  and  Welti, 
who  have  shown  that  broken-down  red  corpuscles,  blood  pigment 
and  thrombi  of  blood  plaques,  or  undeveloped  elements  may 
occlude  the  gastric  vessels  and  cause  ulcer;  and  London  explains 
the  gastric  ulcers  in  malaria  by  the  occurrence  of  pigment  emboli. 
Tolma  produced  gastromalacia  and  gastric  ulcers  by  ligating  the 
esophagus  of  dogs  above  the  cardia  and  the  duodenum  below  the 
pylorus  (Tolma,  "  Untersuch.  iiber  Ulcus  ventric,"  etc.,  ZcitscJir.  f. 
klin.  Med.,  Bd.  xvii,  S.  10).  This  experiment  constitutes  too  violent 
an  interference  with  normal  gastric  physiology  to  permit  of  any 
correct  deductions. 

It  is  impossible  to  differentiate  the  effects  of  violent  trauma,  inter- 
ference with  the  venous,  arterial,  and  lymph  supply,  intragastric 
stagnation,  fermentation,  and  sepsis,  that  the  experiment  of  Tolma 
brings  about. 

Views  Concerning  Causative  Circulatory  Disturbances. — 
Virchow  called  attention  to  the  frequency  of  gastric  ulcers  in 
anemia  and  chlorosis,  explaining  it  by  the  diseases  of  the  vessel 
walls,  fatty  degenerations,  aneurysmal  and  varicose  dilatations,  and 
their  consequences,  viz. :  thrombosis  and  embolism.  Cohnheim 
conceded  the  casual  relations  of  these  states,  but  disputed  the  fre- 
quency of  their  occurrence,  (i)  because  the  abundant  anastomoses 
between  the  gastric  vessels  facilitate  a  compensatory  collateral  cir- 
culation ;  (2)  because  the  diseases  of  the  vessel  walls  referred  to 
are  rare  in  young,  but  frequent  in  old  persons,  which  would  indi- 
cate that  in  these,  gastric  ulcer  should  be  found  frequently,  whereas 
in  later  life  it  is  very  rare.     Klebs  has  a  theory  attributing  gastric 


466  ULCER    OF    THE    STOMACH. 

ulcer  to  local  ischemia,  supposed  to  be  caused  by  spastic  arterial 
contractions.  Rindfleisch's  opinion  is  that  venous  stasis  in  the  gas- 
tric walls  may  lead  to  ulcer,  since  occlusion  of  the  exit  of  the  blood 
may  occur  easily  on  account  of  the  compressibility  and  the  few  anas- 
tomoses in  the  gastric  veins  ;  this,  he  thinks,  may  cause  hemorrhage, 
erosions,  and  ulcer.  Cohnheim  opposes  this  view  also,  because 
gastric  ulcer  is  a  rare  thing  in  the  passive  congestion  due  to  hepatic 
cirrhosis.  One  must  not  overlook  the  fact,  however,  that  in  this 
state  the  secretion  of  HCl  is  much  reduced.  Axel  Key  assumes 
that  long  and  persisting  contractions  of  the  musculature  may  cause 
local  ischemias  or  disturbances  in  the  venous  outflow.  Bottcher 
and  Letulle  attribute  the  causation  of  ulcer  to  bacteria,  which  they 
could  demonstrate  in  colonies  in  the  floor  and  in  the  surroundings 
of  ulcer. 

Most  of  the  observers  mentioned  make  the  statement  that  gastric 
ulcers  produced  experimentally  in  animals  heal  rapidly.  The 
mucosa  is  replaced  almost  completely ;  a  new  formation  of  peptic 
glands  has  been  observed  by  Grifinni,  Hauser,  and  Vassali.  At 
autopsies,  cicatrices  are  often  found  in  the  human  stomach,  where 
no  symptoms  referable  to  ulcer  were  evident  during  life.  It  is 
known,  also,  that  pieces  have  been  torn  loose  by  the  suction  of  the 
lower  end  of  the  stomach-tube,  and  yet  this  loss  of  substance 
healed  without  forming  an  ulcer;  so  that  repair  may  follow  injury 
to  the  human  stomach,  and  it  is  very  evident  that  some  other 
causatory  factors  besides  injury  are  necessary  to  bring  about  an 
ulcer.  A  pathological  composition  of  the  blood  has  been  thought 
to  be  one  of  these  factors,  particularly  as  gastric  ulcer  is  very  fre- 
quently found  in  anemia  and  chlorosis.  This  view  is  supported  by 
the  experiments  of  Quinke  and  Daettwyler,  who  produced  a  high 
degree  of  anemia  by  gradual  withdrawal  of  blood  from  dogs. 
Thereafter,  they  produced  gastric  injuries  by  mechanical,  chemical, 
and  thermic  irritants,  and  discovered  that  ulcers  were  formed  that 
healed  with  much  difficulty.  Clinical  experience  confirms  these 
observations,  that  an  impaired  state  of  the  blood  may  greatly  pro- 
tract healing.  On  the  other  hand,  there  are  numerous  records  of 
severe  and  recurrent  attacks  of  gastric  ulcer  in  persons  whose 
blood  was  found  perfectly  normal. 

Hyperacidity  (one  of  the  etiological  factors). — In  the  second 
volume  of  Reynolds'  "  System  of  Medicine,"  page  930,  W.  Fox 
expresses  the  opinion  that  the  cause  of  chronicity  of  ulcer  may  be 


HYPERACIDITY    AS    A    CAUSE.  467 

"an  excessive  acidity  or  secretion  of  the  gastric  juice,  particularly 
when  the  stomach  was  empty."  But  to  Riegel  belongs  the  credit  of 
having  placed  this  condition  of  hyperacidity  with  gastric  ulcer  upon 
a  scientific  basis.  His  results  were  confirmed  by  von  den  Velden, 
Jaworski,  Korcynski,  Ewald,  and  Boas. 

According  to  our  experience,  hyperacidity  is  present  in  88  per 
cent,  of  undoubted  gastric  ulcers.  Riegel  at  first  asserted  that  it 
was  a  constant  accompaniment  (F.  Riegel,  "  Beitrage  zur  Diagnostik 
d.  Magenkrankheiten,"  Zeitsclir.f.  klin.  Med.,  Bd.  xii,  S.  434).  But 
Gerhardt,  Rosenheim,  Ritter,  von  Mehring,  Cahn,  and  Hirsch  pub- 
lished cases  of  gastric  ulcer  with  normal  and  even  subnormal  acidities. 

The  methods  of  Cahn  and  v.  Mehring  we  have  thoroughly  tested, 
and  assured  ourselves  that  it  gives  values  that  are  too  low  for  the  free 
HCl,  which  may  explain,  in  part,  some  of  the  results  and  discrepan- 
cies of  Rosenheim  and  the  originators  of  the  method.  We  do  not 
deny  that  there  are  undoubted  cases  of  gastric  ulcer  in  which  there 
is  a  subnormal  amount  of  HCl,  but  they  are  exceedingly  rare.  It 
is  well  known  that  ulcer  may  be  associated  with  gastritis,  which 
may  have  reached  the  stage  of  glandular  atrophy  and  become  the 
cause  of  the  sub-  or  anacidity.  Whenever  the  glandular  layer  is 
intact  it  is  reasonable  to  expect  hyperacidity,  because  the  presence 
of  an  ulcer  is  a  never-ceasing  irritation.  Riegel  asserts  that  in  con- 
sequence of  and  by  means  of  this  hyperacidity  an  ulcer  may 
develop  from  an  erosion  or  injury  of  the  mucosa,  which,  though 
seemingly  unimportant  in  itself,  is  retarded  in  its  healing  by  autodi- 
gestion.  Of  course,  it  is  intelligible  (as  Ewald,  Ritter,  and  Hirsch 
point  out)  that  the  hyperacidity  may  be  the  result  just  as  well  as 
the  primary  cause  of  ulcer.  It  is  probable  that  the  Jiyperacidity 
may  change  normal  clonic  contractions  of  the  gastric  muscularis 
to  intense  tonic  spasms  that  last  an  unnaturally  long  time  and  pro- 
duce local  ischemia  and  impediments  to  the  exit  of  venous  blood. 
This,  if  it  occurs,  must  inevitably  be  followed  by  circulatory  disturb- 
ances and  changes  in  nutrition  of  the  mucosa,  and  eventually  by 
hemorrhages  of  a  circumscribed  character,  out  of  which  the  auto- 
digestive  process  may  form  erosions  and  ulcers. 

Etiology. — The  deductions  from  the  preceding  summary  of 
experiments  and  observations  are,  above  all,  the  establishing  of 
four  principal  factors  in  the  etiology  of  ulcer : 

I.  An  impaired  vitality  or  resistance  of  portions  of  the  mucosa. 
II.  Hyperacidity  or  supersecretion. 

31 


468  ULCER    OF    THE    STOMACH. 

III.  An  altered  state  of  the  blood. 

IV.  Local  bacterial  infection. 

There  are  a  number  of  well-authenticated  cases  on  record,  prov- 
ing that  direct  trauma  may  cause  gastric  ulcer  (vide  Einhorn,  loc. 
cit,  p.  191  ;  also  others  reported  by  C.  Hoffmann,  Leube,  and 
Eichhorst). 

According  to  Sidney  Martin  [loc.  cit.,  p.  410),  there  are  three  com- 
mon causes  of  the  death  of  the  tissue  which  precedes  ulceration  : 

(i)  Mcclianical  and  Chemical  Causes. — Ingested  fish-bones,  egg 
and  oyster  shells,  seeds,  etc.  Corrosive  poisons  lead  to  ulceration 
by  directly  destroying  the  tissue  ;  and  an  injury  to  the  mucous 
membrane,  which  is  subsequently  exposed  to  the  continued  action 
of  an  irritant,  will  also  lead  to  an  ulcer. 

Direct  injury  and  wounding  of  the  gastric  mucosa  occur  very 
frequently,  and,  as  a  rule,  heal  very  rapidly.  There  are  a  number 
of  cases  on  record  of  persons  swallowing  glass,  nails,  and  knives, 
which  passed  through  the  entire  intestine  without  causing  injury. 
Marcet  ("  Med.  Chirur.  Transactions,"  vol.  xii,  p.  72)  narrates  the 
case  of  an  American  sailor  swallowing  some  30  pieces  of  knife- 
blades,  which  were  found  in  his  stomach,  together  with  a  number 
of  handles.  Two  blades  were  in  the  colon  and  rectum,  placed 
transversely,  and  had  perforated  the  intestinal  wall  without  causing 
peritonitis.     No  recent  or  old  ulcers  were  found  in  the  stomach. 

The  following  report  from  the  German  Hospital,  of  Kansas  City, 
goes  to  show  that  this  class  of  human  ostriches  has  not  died  out. 
The  main  fact  that  is  proved  by  such  cases  is!  that  something  else 
is  needed  in  addition  to  direct  injury  to  the  stomach  in  order  to 
produce  an  ulcer. 

German  Hospital,  Kansas  City,  Mo.,  June  14th. — Harry  Whallen,  the 
"human  ostrich,"  who  was  operated  upon  at  the  German  Hospital  last  Satur- 
day, and  from  whose  stomach  the  surgeon  took  an  assortment  of  cutlery  and 
hardware,  died  at  two  o'clock  this  morning,  the  result  of  the  operation. 

Whallen  got  into  trouble  by  swallowing  a  big  Barlow  knife,  in  Pilot  Grove, 
Mo.,  the  other  day.  When  he  was  operated  upon  at  the  German  Hospital  these 
articles  were  removed  from  his  stomach  : 

Two  jack-knives,  one  three  inches  long  and  the  other  four  inches ;  five  knife- 
blades,  from  one  to  three  inches  long ;  32  wire  nails,  eightpenny  or  larger  ; 
34  sixpenny  nails,  26  shingle  nails,  16  carpet  tacks  and  small  wire  nails,  one 
barbed  wire  staple,  one  horseshoe  nail,  three  screws,  three  ounces  of  glass,  and 
several  bits  of  crockery. 

Whallen  was  offering  bets  that  at  least  100  nails  and  three  knives  would  be 
found  in  his  stomach,  and  if  the  referee  had  decided  that  five  single  blades  are 


BACTERIAL    INFECTION.  469 

equivalent  to  one  knife,  he  would  have  w^on  his  bets.  He  w^as  a  professional 
showman.  He  began  swallowing  glass  and  nails  when  he  was  ten  years  old, 
and  says  he  has  eaten  a  lamp  chimney  nearly  every  day  during  the  seventeen 
years  he  has  been  at  it,  but  the  Barlow  knife,  which  he  swallowed  last  week, 
was  too  much,  even  for  his  long-suffering  stomach. 

When  the  surgeons  operated  upon  him,  the  stock  of  hardware  inventoried 
was  found  imbedded  in  a  solid  mass  in  his  stomach  and  partially  encysted. 
After  it  was  removed  the  stomach  was  thoroughly  washed  out  and  sewed  up. 

(2)  Interference  zvith  the  Vitality  of  the  Tissue. — The  vitality  of  a 
particular  part  of  the  mucous  membrane  may  be  diminished  by 
local  and  chronic  disease  or  by  interference  with  the  circulation 
over  a  certain  area.  This  latter  usually  occurs  by  means  of 
thrombosis  or  embolism.  Thrombosis  takes  place  in  connection 
with  disease  of  the  vessels  and  in  association  with  inferior  quality 
of  the  blood  and  a  slowing  of  the  local  circulation ;  embolism  may 
be  infective  or  noninfective,  and  is  usually  capillary. 

(3)  Bacterial  Infection. — The  infective  processes  of  the  digestive 
mucosa  with  which  we  are  most  familiar,  are  the  ulceration  pro- 
cesses of  typhoid  fever,  certain  dysenteries,  and  tuberculosis.  In 
the  gastric  ulcer,  however,  there  is  another  kind  of  bacterial  infec- 
tion, which  is  not  accompanied  with  the  signs  of  active  inflam- 
mation, and  is  termed  by  some  authors  "  bacterial  necrosis." 

The  process  is  characterized  by  the  invasion  of  bacteria,  usually 
in  the  lower  depths  of  the  mucous  membrane,  by  their  growth 
and  subsequent  necrosis  of  the  tissue.  Although  the  secretion  of 
HCl  is  germicidal  to  many  bacteria,  it  must  be  remembered  that 
the  spores  are  not  destroyed  by  it,  and  that  the  invasion  may  take 
place  during  the  periods  of  rest  of  the  glands  in  the  intervals  of 
digestion  when  no,  or  very  little,  HCl  is  secreted.  There  is 
room  for  the  suggestion  that  the  primary  necrosis  is  due  to  bac- 
teria and  the  ensuing  ulceration  caused  by  the  action  of  the  gas- 
tric juice.  The  bacteria  can  exist  in  the  cells  around  and  beneath 
the  floor  of  the  ulcer,  and  notwithstanding  a  very  high  degree  of 
hyperacidity. 

In  a  number  of  cases  which  we  examined  by  the  most  approved 
cellular  and  bacterial  stains,  the  bacteria  were  present  throughout 
the  layers,  even  in  the  peritoneum,  while  the  floor  of  the  ulcer 
was  in  the  muscularis.  It  is  conceivable  that  they  pave  the 
way  for  autodigestion  by  causing  necrosis  of  the  tissues  in 
which  they  are  imbedded.  No  bacterium  was  so  far  obtained  in 
pure  culture,  but  the  one  most  frequently  observed  was  a  bacillus 


470 


ULCER    OF    THE    STOMACH. 


very  much  resembling  that  of  anthrax  and  in  two  cases  of  ulcus 
carcinomatosum  the  Oppler-Boas  bacillus. 

TJicrniic  causes  are  the  ingestion  of  very  hot  food  and  drink, 
taken  when  the  organ  is  empty. 

An  interesting  etiological  relation  exists  between  cutaneous 
burns  and  gastric  or  duodenal  ulcers. 

The  last  two  factors,  hot  food  and  large  cutaneous  burns,  explain 
the  rather  frequent  occurrence  of  gastric  ulcer  which  is  said  to 
occur  among  cooks,  who  are  in  the  habit  of  tasting  foods  that  are 
still  on  the  fire,  and  also  liable  to  frequent  burns. 

Co7istitntional  causes  are  generally  brought  about  by  such  dis- 
eases as  effect  alterations  and  degeneration  either  in  the  compo- 
sition of  the  blood  or  in  the  vessels.  These  are  chlorosis,  anemia, 
syphilis, tuberculosis, arteriosclerosis,  fatty, amyloid,  and  aneurysmal 
degenerations  of  arteries,  thrombi,  emboli,  trichinosis,  and  malaria. 

Effect  of  pressure  exerted  upon  the  stomach  by  the  costal  mar- 
gins is  claimed  to  induce  anemia  and  atrophy  of  the  mucosa, 
especially  in  the  region  of  the  smaller  curvature.  Habershon  and 
Rasmussen  have  advanced  this  view,  in  explanation  of  the  fre- 
quency of  gastric  ulcer  in  those  whose  occupations  necessitate  con- 
tinual pressure  on  the  stomach. 

Influence  of  Age. — In  order  to  determine  from  postmortem 
records  the  age  at  which  gastric  ulcer  most  frequently  occurs,  all 
cases  in  which  only  cicatrices  are  found  should  be  excluded, 
because  a  cicatrix  gives  no  evidence  as  to  the  age  at  which  the 
ulcer  existed.  The  best  statistics  on  this  subject  are  contained  in 
Welch's  article  on  Gastric  Ulcer  in  Pepper's  "  System  of  Medicine," 
volume  II,  page  483.  The  statistics  of  Brinton,  which  are  still  cited  in 
the  last  editions  of  Boas,  Fleischer,  Sidney  Martin,  Fleiner,  Debove 
and  Remond,  and  others,  include  all  cicatrices  found  at  autopsies 
as  open  ulcers.  The  following  table  is  given  by  Welch,  repre- 
senting the  age  in  607  cases  of  open  ulcer,  collected  from  hospital 
statistics  : 


Age,    . 

I-IO 

10-20 

20-30    30-40 

40-50    50-60 

60-70    70-So 

80-90  90-100 

Over 
100 

No.  of 
Cases, 

I 

32 

119    ■    107 

114        108 

84         35 

6 

0 

I 

.1, 

^                                           , 

^                                                                , 

Totals, 

■hi 

226 

222 

119 

7 

FREQUENCY    OF    GASTRIC    ULCER.  4/1 

From  this  table  it  is  apparent  that  the  largest  number  of  cases 
is  found  between  twenty  and  thirty.  Three-fourths  of  the  cases 
occur  between  twenty  and  sixty. 

In  41,688  cases,  constituting  the  clinical  material  in  Zurich  and 
Breslau  between  the  years  1853  and  1873,  252  cases  of  gastric 
ulcer  were  diagnosed  during  life  by  Lebert ;  nearly  seven-tenths  were 
between  twenty  and  forty  years  of  age, — a  preponderance  suffi- 
ciently great  to  be  of  diagnostic  value  in  the  differentiation,  as 
we  shall  see  later  from  carcinoma,  for  in  this  disease  the  largest 
number  of  cases  is  found  between  fifty  and  sixty  years.  Goodhart 
has  described  a  case  of  gastric  ulcer  in  a  child  thirty  hours  old. 

Influences  of  Sex. — Females  are  more  frequently  affected  than 
males  ;  the  following  are  the  figures  given  by  various  authors  : 

Males.  Females. 

Welch, 40  per  cent.  60  per  cent,  in  1699  cases  of  gastric  ulcer 

found  at  autopsy. 
Brinton's  ratio,  ...       I  male  to  every  2  females. 
Anderson,  .....       3  males  and  32  females  in  35  cases. 
Habershon,     ....     74  males  and  127  females  in  201  cases. 

The  nursing  period,  puerperium,  and  menstruation  are  also 
claimed  to  increase  the  susceptibility  to  ulcer. 

Geographical  Distribution. — There  seems  to  be  an  unequal  geo- 
graphical distribution  of  the  disease,  which  seems  to  be  more 
common  in  northern  than  in  southern  countries.  It  is  less  com- 
mon in  this  country  than  in  England  and  Germany,  according  to 
Da  Costa,  Keating,  and  Welch  {loc.  cit.,  p.  485).  The  last-men- 
tioned author  found  only  six  cases  of  gastric  ulcer  in  800  autopsies 
made  by  him  in  New  York.  In  444,564  deaths  in  New  York  City, 
from  1868  to  1882,  ulcer  of  the  stomach  was  assigned  as  the  cause 
in  only  410  cases.  To  these  statistics  little  importance  can  be 
attached,  because  they  are  compiled  from  reports  of  practitioners 
of  varying  diagnostic  skill,  and  concern  a  disease  that  presents 
many  difficulties  of  recognition. 

The  Frequency  of  Gastric  Ulcer. — We  quote  the  following 
from  Professor  Welch's  article  (loc.  cit.) : 

In  32,052  autopsies  made  in  Prague,  Berlin,  Dresden,  Erlangen, 
and  Kiel,  there  were  found  1522  cases  of  open  ulcer  or  of  cica- 
trix in  the  stomach.  If  all  the  scars  be  reckoned  as  healed  ulcers, 
according  to  these  statistics  gastric  ulcer,  either  cicatrized  or  open, 
is  found  in  about  five  per  cent,  of  persons  dying  from  all  causes. 


4/2  ULCER    OF    THE    STOMACH. 

It  is  important  to  note  the  relative  frequenc}'  of  open  ulcers 
as  compared  with  that  of  cicatrices.  In  ii, 888  bodies  examined 
in  Prague,  there  were  found  164,  or  1.4  per  cent.,  with  open  ulcers, 
and  373,  or  3.1  per  cent.,  with  cicatrices.  Here  scars  were  found 
about  two  and  one-fourth  times  as  frequently  as  open  ulcers.  The 
observations  of  Griinfeld  in  Copenhagen  show  that  when  especial 
attention  is  given  to  searching  for  cicatrices  in  the  stomach,  they 
are  found  much  more  frequently  than  the  figures  here  given  would 
indicate.  It  would  be  a  moderate  estimate  to  place  the  ratio  of 
cicatrices  to  open  ulcers  at  three  to  one. 

The  statistics  concerning  the  average  frequency  of  open  ulcers 
are  much  more  exact  and  trustworthy  than  those  relating  to  cica- 
trices. It  may  be  considered  reasonably  certain  that,  at  least  in 
Europe,  open  gastric  ulcers  are  found  on  the  average  in  from  one 
to  two  per  cent,  of  persons  d}'ing  from  all  causes. 

It  is  manifestly  impossible  to  form  an  accurate  estimate  of  the 
frequency  of  gastric  ulcer  from  the  number  of  cases  diagnosed  as 
such  during  life,  because  the  diagnosis  is  in  many  cases  uncertain. 
Hence  the  importance  of  autopsy  statistics. 

Von  Jaksch  (cited  by  Bamberger,  "  Handbuch  d.  speciel.  Path.  u. 
Therap.,"  von  Virchow,  vi,  i.  Abth.,  280)  states  that  113  ulcers  or 
cicatrices  were  found  in  2330  autopsies,  i.  e.,  4.8  per  cent.  Orth 
gives  five  per  cent. 

Berthold's  statistics  from  the  "  Charite,"  Berlin,  from  1S68  to 
1882,  give  294  cases, — 2.7  per  cent.  ("  Statist.  Beitrage  z.  Kennt.  d. 
chronischen  Magengeschwiirs,"  Sections-ProtocoU  d.  Path.  Inst., 
Berlin). 

Nolte,  Miinchen,  1876  to  1883,  gives  3500  autopsies,  with  43 
ulcers,  or  1.23  per  cent.  ("  Haufigkeit  d.  Magengeschwiirs  in 
Miinchen,"  Dissert.,  1883). 

Berthold  (cited  from  Ewald,  "  Diseases  of  the  Stomach,"  p. 
233)  gives  the  percentage  of  ulcer  of  the  stomach  for  Berlin  as 
2.7  per  cent.;  Nolte,  for  Munich,  as  1.23;  Gries,  for  Kiel,  as  8.3; 
Stark,  for  Copenhagen,  as  13  per  cent.  Von  Sohlern  ("  Der  Einfluss 
der  Ernahrung  auf  die  Entstehung  des  Magengeschwiirs,"  Berlin, 
klin.  WocJienschr.,  1889,  No.  14)  has  lately  called  attention  to  the  fact 
that  the  Roen  Mountains  and  the  Bavarian  Alps  (Germany)  and 
the  greater  part  of  Russia  are  nearly  exempted  from  gastric  ulcer. 
The  diet  upon  which  the  inhabitants  of  these  countries  subsist 
consists  largely  of  amylaceous  and  vegetable  substances  containing 


SYMPTOMATOLOGY.  473 

a  large  percentage  of  potassium  salts.  The  blood  of  persons  livdng 
largely  or  exclusively  on  a  vegetarian  diet  (Japanese)  is  very  rich 
in  potassium  phosphate.  According  to  von  Sohlern.the  exemption 
from  gastric  ulcer  observed  among  these  peoples  is  due  to'the  large 
amount  of  potassium  introduced  in  their  food.  We  are  not  aware 
that  von  Sohlern  has  supported  his  theory  by  quantitative  blood 
anah^ses. 

Symptomatology. — The  most  characteristic  subjective  signs  of 
gastric  ulcer  are  localized  pain,  vomiting,  hematemesis,  disturb- 
ances of  secretion,  the  presence  of  blood  in  the  stools,  and  the  state 
of  the  appetite.  Frequently  all  these  symptoms  occur  together; 
at  other  times  only  one  or  the  other  single  symptom  becomes 
prominent.  There  are  cases  of  gastric  ulcer  that  run  a  latent 
course,  without  any  characteristic  symptoms  whatever. 

We  will  begin  with  a  consideration  of  the  excessive  secretion  of 
HCl.  This  is  a  result  of  the  irritation  of  the  gastric  nerves, 
either  by  the  inflammation  caused  by  the  ulcer  itself,  or  by  irrita- 
tion of  exposed  nerve-fibers,  caused  by  the  contents  of  the  stomach. 
Although  the  secretory  nerves  of  the  stomach  have  as  yet  not 
been  demonstrated  as  definitely  as  the  secretory  nerves  of  the  sali- 
vary and  lachrymal  glands,  we  are  justified  in  assuming  their  exist- 
ence on  pathological  and  clinical  grounds.  Just  as  the  eye  will 
overflow  with  tears  until  an  offending  foreign  body  has  been  removed, 
and  just  as  the  saliva  will  be  secreted  when  the  mucous  mem- 
brane of  the  mouth  is  stimulated  by  food,  or  when  there  are  ulcers 
or  inflammations  present  in  the  .buccal  cavity,  so  in  a  similar  manner 
the  gastric  mucosa  will  respond  to  irritation  of  its  nerve-fibers  by 
an  augmented  secretion.  This  irritation  may  be  caused  by  the 
ulcer  itself,  exposing  and  corroding  the  terminal  nerve-fibers. 

The  entire  gastric  nerve  apparatus  is  placed  in  a  state  of  increased 
excitability  through  the  presence  of  an  ulcer,  and  when  food  reaches 
the  stomach  the  mucosa  is  stimulated  with  an  intensity  that  is 
much  greater  than  in  the  normal  stomach.  The  percentage  of  HCl 
present  varies  from  three  to  five  per  looo;  this  strong  gastric 
juice  rapidly  dissolves  albuminous  constituents  of  the  food,  while  the 
carbohydrates  remain  undigested.  Organic  acids  are  absent.  It  may 
happen,  in  rare  cases,  that  the  peristalsis  of  the  stomach  is  inhib- 
ited, causing  retention  of  the  food;  in  such  cases  the  irritation  of 
the  nerves  is  kept  up  as  long  as  food  is  present  in  the  stomach, 
constituting  continued  hypersecretion.     We  have  to  distinguish  in 


474  ULCER    OF    THE    STOMACH. 

these  cases  between  two  kinds  of  excess  of  gastric  juice  :  (i)  the 
digestive  hyperacidity,  which  occurs  when  the  motility  is  good,  only 
during  the  normal  presence  of  ingesta  in  the  stomach  ;  (2)  the  con- 
tinued hvpei'secretion,  which  occurs  as  soon  as  the  motility  is  im- 
paired, when  food  is  present  at  all  times  in  the  organ.  With  a  con- 
tinued hypersecretion  the  glandular  cells  graduall}'  become  ex- 
hausted ;  they  eventually  secrete  a  juice  which  is  much  poorer  in 
HCl  and  pepsin  than  the  normal  product,  just  as  the  exhausted 
salivary  gland-cells  secrete  a  saliva  which  is  very  poor  in  ptyalin. 
The  exhaustion  of  the  gastric  gland-cells  may  explain  the  observa- 
tion referred  to,  where  hyperacidity  was  absent  in  cases  of 
undoubted  gastric  ulcer.  The  fact  was,  the  glands  had  become  so 
exhausted  that  it  was  impossible  for  them  to  form  their  characteristic 
product. 

The  paiji  of  gastric  nice?' IS  caused  by  irritation  of  the  sensory 
nerves  in  the  base  of  the  corroded  area.  It  occurs  with  great  in- 
tensity immediately  after  the  ingestion  of  food,  and,  as  a  rule,  in- 
creases with  the  augmentation  of  acid  during  digestion.  The  pain 
during  the  digestive  act  is  most  probably  caused  also  by  the  peris- 
taltic movements,  drawing  upon  and  compressing  the  ulcer.  Ex- 
ternal pressure  will  produce  sharp  pain  in  the  locality  of  the  ulcer. 
The  pain  is  of  a  burning,  stinging  character,  and  in  some  cases  it 
causes  a  spastic  contraction  of  the  sphincter  of  the  pylorus  re- 
flexly — a  reflex  pylorospasm,  which  in  itself  may  be  very  painful. 
Some  patients  complain  frequently  of  a  sore  spot  in  the  epigas- 
trium. In  cases  of  gastric  ulcer  associated  with  pylorospasm  the 
pain  radiates  from  the  epigastrium  toward  the  right  and  left,  reach- 
ing the  spinal  column.  Traube  called  attention  to  well-defined  ir- 
radiations of  the  pain  into  the  domain  of  other  nerves  outside  of 
the  stomach.  Attacks  of  angina  pectoris,  intercostal  neuralgias, 
and  neuralgias  in  the  left  brachial  plexus  have  been  described  by 
Brinton ;  sympathetic  neuralgias  in  the  arms  and  legs  have  been 
referred  to  by  M.  Miiller. 

The  intercostal  nerves  of  the  left  side  may  be  in  a  more  sensi- 
tive condition  earlier  than  those  of  the  right  side;  this  may  reveal 
itself  by  a  hyperesthesia  of  the  skin  and  soft  parts  in  the  lower 
left  parts  of  the  thorax,  upper  portions  of  the  abdomen,  and  in  the 
lumbar  region.  The  slightest  touch,  the  pressure  of  the  clothes 
and  bed-covers  may  be  unpleasant  to  such  patients. 

Female  patients  can  not  wear  a  corset.     Very  frequently  the  pain 


VOMITING.  475 

has  a  penetrating,  lancinating  character,  shooting  from  the  epigas- 
trium straight  through  to  the  spinal  column.  The  influence  of  the 
ingestion  of  food  on  the  pain  is  very  evident,  although  there  are 
painful  sensations  when  the  stomach  is  empty  ;  these  sensations 
partake  more  of  the  nature  of  soreness  and  hunger.  This  may  be 
momentarily  relieved  by  the  taking  of  food,  only  to  become  more 
severe  by  the  stimulation  and  the  hyperacid  secretion  that  are  set  up 
by  it.  Liquid  food  may  pass  through  the  stomach  without  causing 
much  annoyance,  whereas  solid  food  is  always  distressing.  Very 
cold  or  very  hot  food  invariably  causes  this  gastralgia.  The  pain 
usually  occurs  within  a  half  hour  after  ingestion.  Should  it  not 
occur  until  an  hour  and  a  half  to  two  hours  after  meals,  this 
would  justify  the  suspicion  of  an  ulcer  below  the  pylorus  in  the 
duodenum,  whereas  if  the  pain  occurs  at  once,  during  the  act  of 
deglutition,  an  ulcer  in  the  lower  part  of  the  esophagus  should  be 
suspected.  Lying  on  the  left  side  increases  the  pain  (Leube), 
whereas  absolute  quiet  and  resting  on  the  back  relieves  it. 

Pyrosis. — There  is  in  most  cases  a  very  annoying  burning  feeling 
in  the  left  hypochondrium  and  epigastrium,  frequently  rising  to  the 
throat.  Some  patients  locate  it  posterior  to  the  sternum,  or  even 
between  the  shoulder-blades  ;  this  so-called  "  heart-burn  "  is  caused 
by  irritation  of  the  stomach  and  esophagus  by  excessively  acid 
gastric  contents.  If  the  burning  is  very  marked  in  the  esophagus 
we  may  presume  that  abnormal  peristalsis  of  the  stomach  and  in- 
sufficiency of  the  cardia  are  co-operative  in  bringing  about  the 
pyrosis. 

TJie  Condition  of  the  Appetite. — In  our  experience  the  appetite 
is  either  normal  or  increased  in  the  majority  of  cases.  The 
instances  where  the  appetite  is  positively  lost  are  very  rare. 
Before  accepting  a  state  of  anorexia  it  is  necessary  to  distinguish 
whether  food  is  refused  because  the  patients  have  no  feeling  of 
hunger,  or  whether  they  will  not  eat  because  they  dread  the  pain 
caused  thereby.  Thirst  is  usually  increased,  and  the  tongue  is 
clean. 

Vomiting. — The  irritation  and  the  hyperacidity  set  up  by  the 
presence  of  the  ulcer,  cause  increased  peristalsis  and  antiper- 
istalsis.  The  peristaltic  unrest  is  accompanied  by  a  feeling  of 
boring  undulation  in  the  eprgastrium.  It  may  involve  the  intestine, 
causing  gurgling,  rumbling  noises.  The  rapid  evacuation  of  the 
stomach,  caused  by  the  intensified  peristalsis,  is  rather  favorable  to 


4/6  ULCER    OF    THE    STOMACH. 

recovery,  because  it  brings  on  a  speedy  return  of  the  contracted  state 
which  favors  approximation  of  the  edges  of  the  ulcer  and  healing. 
When  the  pylorus  is  tightly  closed  by  spasmodic  contraction, 
the  food  masses  remain  much  longer  in  the  stomach,  and  the 
mucosa  is  excessively  irritated  by  the  intensely  acid  contents. 
The  stomach  is  then  distended  by  the  constant  afflux  of  gastric 
juice  and  saliva  ;  also  by  the  aspiration  of  air,  which  occurs  fre- 
quently in  these  conditions.  The  distention  causes  a  drawing 
apart  of  the  edges  of  the  ulcer,  pain,  antiperistaltic  movements,  and 
eventually  vomiting.  Pylorospasm  is  a  very  grave  accompaniment, 
since  it  gives  rise  to  gastric  hemorrhages  and  new  erosions  by  the 
development  of  the  conditions  just  described.  The  vomited  matter 
generally  shows  a  good  digestion  of  proteids  and  imperfect  diges- 
tion of  carbohydrates. 

Hemateiiiesis. — This  is  probably  the  most  characteristic  sign  of 
ulcer.  It  only  occurs  in  about  half  the  cases.  Jaworski  and 
Korczynski  {loc.  cit?)  assert  that  the  acidity  is  very  much  increased 
immediately  before  and  after  the  hematemesis.  This,  of  course, 
would  explain  the  digestion  of  the  blood  and  the  conversion  of 
oxyhemoglobin  into  hematin  hydrochlorate.  The  amount  of  the 
vomited  blood  does  not  give  a  correct  impression  of  the  degree  of 
the  hemorrhage,  because  considerable  quantities  of  the  blood 
escaping  into  the  stomach  reach  the  intestine  and  are  passed  out 
in  form  of  tarry  stools.  The  intestinal  evacuations  may  contain 
blood  several  days  after  the  hematemesis. 

The  production  of  gastric  hemorrhage  is  favored  by  bodily 
movement,  but  it  may  occur  during  rest,  even  during  sleep. 
When  very  small  quantities  of  blood  escape  into  the  stomach,  they 
mix  with  the  contents,  are  partially  digested,  and  eventually  come 
up  in  the  form  of  coffee-ground  material.  When  larger  vessels 
are  corroded  by  the  ulcer  we  have  copious  hemorrhages  of  dark- 
red,  pure  blood.  A  profuse  hemorrhage,  therefore,  as  a  rule,  points 
to  a  deep  ulcer.  Gastric  hemorrhages  are  accompanied  by  the 
systemic  phenomena  of  internal  hemorrhages  in  any  other  part 
of  the  body,  such  as  sinking  of  arterial  pressure,  marked  pallor, 
sensations  of  warmth  and  pain  in  the  stomach,  cardiac  oppres- 
sion, nausea,  cold  sweat,  fainting,  and  collapse.  Death  has  been 
known  to  occur  in  the  state  of  collapse  before  any  blood  was 
vomited,  the  autopsy  showing  enormous  quantities  of  liquid  and 
coasfulated  blood.     In  one  case  a  solid  blood-clot  filled  the  entire 


DIAGNOSTIC    PAIN    POINTS.  47/ 

stomach.  Bodily  exertions,  the  external  application  of  force  of 
any  kind  to  the  region  of  the  stomach,  and  straining  at  stool  have 
repeatedly  been  reported  as  the  direct  causes  of  gastric  hemorrhage. 
In  patients  with  persistent  pain  in  the  stomach,  and  dark-colored 
stools,  the  latter  should  be  examined  for  blood-coloring  matters 
by  testing  for  the  hemin  crystals.  Iron,  bismuth,  tannic  acid, 
tea,  claret,  and  huckleberries  may  produce  a  black  color  of  the 
stool. 

77^1?  state  of  the  boivels  is  mostly  that  of  persistent  constipation  ; 
sometimes  the  evacuations  are  normal  ;  this  is  generally  the  case 
when  much  water  has  been  ingested  to  quench  the  intense  thirst. 
The  small  quantity  of  the  evacuations  is  explained  by  the  fact  that 
very  little  food  is  ingested,  and  this  is  so  thoroughly  dissolved  in 
its  proteid  constituents  by  the  very  active  gastric  juice  that  little 
work  remains  for  the  intestine.  Often  the  pylorospasm,  the 
cicatricial  contraction  of  the  pylorus,  and  the  frequent  vomiting 
are  agents  in  producing  constipation,  because  they  prevent  the 
transit  of  the  food  into  the  duodenum.  Colitis  and  membranous 
dysentery  may  co-exist  with  gastric  ulcer  in  rare  instances. 

The  tirine  is  very  much  diminished  in  quantity,  and  is  frequently 
highly  acid  when  no  emesis  has  occurred  ;  but  when  there  has  been 
much  vomiting,  or  when  the  stomach  has  been  washed  out  fre- 
quently, the  urine  may  become  alkaline.  Maly  and  Quincke  have 
observed  that  the  excretion  of  the  alkaline  constituents  of  the 
blood  goes  hand-in-hand  with  the  increased  acid  secretion  of  the 
stomach  ;  at  the  same  time  the  total  chlorids  of  the  urine  are  very 
much  reduced.  The  results  of  Chas.  E.  Simon  {Joe.  cit.)  indicate 
that  exact  analyses  of  the  urine  respecting  its  alkalinity,  the  sub- 
normal amount  of  chlorids,  and  the  excess  of  indican,  etc.,  may 
eventually  instruct  us  concerning  the  secretory  processes  in  the 
stomach,  where  it  is  impossible  to  gain  the  gastric  contents  for 
examination.  (For  detailed  information  see  chapter  on  The  Urine 
in  Gastric  Diseases.) 

Diagnostic  Pain  Points. — Of  these  there  are  two  that  are  of  im- 
portance:  («)  the  epigastric  ;  {b)  the  dorsal.  The  epigastric  pain 
point  is  in  the  median  line,  or  slightly  to  the  left,  very  rarely  to 
the  right  of  it.  It  can  not  be  correctly  called  a  point,  because  the 
pain  is  more  or  less  diffuse,  usually  spreading  over  an  area  as  large 
as  the  palm  of  the  hand.  The  exact  limitation  of  the  epigastric 
painful   area  varies   with   the   location   of  the  stomach.     In  most 


4/8  ULCER    OF    THE    STOMACH. 

cases  it  is  close  to  the  xyphoid  cartilage,  but  it  may  be  several  cen- 
timeters below  that  in  cases  of  descent  of  the  stomach,  gastroptosis, 
dilatation,  etc. 

The  epigastric  pain,  which  is  very  sharply  circumscribed  and 
intense,  maybe  associated  with  a  sensation  of  throbbing  and  pulsa- 
tion. The  dorsa/ pa.\n  region, which  was  first  described  by  Cruveilhier, 
is  also  sharply  circumscribed.  It  was  found  in  about  one-third 
of  our  cases  at  a  level  with  the  tenth  to  the  twelfth  thoracic  verte- 
bra. Its  lateral  extent  amounts  to  from  two  to  three  cm.  and  its 
vertical  extent  from  two  to  five  cm.  In  very  rare  instances  there 
is  a  painful  zone  corresponding  to  the  fourth  or  fifth  thoracic  verte- 
bra. Usualh^  the  dorsal  pain  point  is  only  present  on  the  left  side, 
and  Boas  mentions  a  case  in  which  the  dorsal  pain  was  present 
and  no  epigastric  pain  complained  of  The  only  gastric  sensation 
this  patient  had  was  a  feeling  of  pressure  after  the  ingestion  of  food. 
There  was  no  vomiting  nor  blood  in  the  stools.  Pressure  on  the 
epigastric  region  did  not  cause  pain,  but  there  was  an  intensely 
painful  spot  at  the  level  of  the  twelfth  dorsal  vertebra.  The  patient 
later  on  suffered  from  severe  hematemesis. 

Diagnosis. — Wherever  a  chronic  morbid  process  can  be  deter- 
mined  upon  with  accuracy  and  the  characteristic  pain  points  are 


DESCRIPTION   OF  PLATE   VIII. —ULCUS   CARCINOMATOSUM   OF   THE 

PYLORUS. 

Fig.  I. — A  Section  Through  the  Wall  of  the  Stomach,  Showing  the  Edge 
AND  A  Portion  of  the  Base  of  the  Ulcer. 

Objective,  two-thirds;  eyepiece,  two  inches.  Stained  with  hematoxylin  and  eosin. 
The  drawing  is  built  up  from  a  series  of  microscopic  fields.  /  about  15  dia- 
meters. 

d.  Mucous  membrane.  m.  Muscularis  mucosse.  s.  Submucosa.  a.  Base  of 
the  ulcer,  mm.  Muscle-coat  of  stomach,  mc.  Groups  of  cancer  cells  between  the 
bundles  of  muscle-fibers,  dc.  Groups  of  cancer  cells  in  the  edge  of  the  ulcer  in  the 
mucous  membrane,  sc.  Groups  of  cancer  cells  in  the  submucosse.  a.  Necrotic  mem- 
brane lining  the  base  of  the  ulcer. 

Fig.  2. — A  Small  Nodule  from  the  Serous  Co.a.t  of  the  Stomach  Over  the 

Base  of  the  Ulcer. 

Objective,  two-thirds;    eyepiece,   two    inches.      Stained  with   hematoxylin    and    eosin. 

X  about  15  diameters. 

This  figure  gives  a  good  idea  of  one  of  the  nodules  in  the  serosa.  It  is  composed 
entirely  of  a  collection  of  groups  and  masses  of  packed  cancer  cells,  so  closely  packed 
that  the  outlines  of  the  individual  cells  can  not  be  made  out.  Except  for  these  nodular 
thickenings,  the  serosa  was  not  altered,     pc.    Cancer  masses  in  peritoneal  coat. 


PLATE  VUI. 


di'.it 


V\  ^''SWt 


^ 


? 


DIAGNOSIS.  479 

present  at  the  same  time,  the  diagnosis,  according  to  Boas,  should 
be  certain  {loc.ctt,  p.  41).  He  attributes  less  importance  to  analysis 
of  the  gastric  contents.  There  are,  however,  atypical  forms  which 
present  some  difficulty  in  diagnosis.  Thus  there  are  cases  rarely 
observed  in  which  the  patients  never  complain  of  pain,  nor  has  the 
food  any  distressing  effect  upon  the  stomach.  In  other  cases, 
although  pain  is  present,  it  is  not  aggravated  b\-  taking  food.  In 
some  well-diagnosticated  cases,  food  of  all  kinds  was  well  borne. 
In  all  of  these  well-authenticated  forms  the  diagnosis  was  assured 
by  characteristic  unmistakable  s}'mptoms,  such  as  hematemesis 
and  bloody  stools,  coming  on  afterward.  Concerning  hematemesis, 
it  should  be  said  that  the  differentiation  of  pulmonary  from  gas- 
tric hemorrhage  may  become  necessary.  The  differentiation  may 
be  facilitated  by  a  study  of  the  subjoined  scheme  : 

HEMORRHAGES  FROM  THE 
Lung.  Stomach. 

1.  Blood  is  bright  red,  foamy.  I.    Blood  is  dark  brown,  partly  coagulated, 

frequently  mixed   with   food,  sometimes 
acid. 

2.  Physical  signs  point  to  a  pulmonan.-  or  2.  Physical  examination  evinces  a  gastric 
cardiac  affection — the  stomach  may  be  or  hepatic  affection,  or  stasis  in  portal 
affected  secondarily.  circulation. 

3.  Pulmonary  hemorrhages  followed  by  3.  Gastric  hemorrhages  are  frequently  as- 
rusty-colored    sputa    for    days    (gener-  sociated  with  tar-colored  stools. 

ally),   but    there    is    no    blood    in    the 
stools. 

4.  Physical  signs  of  pulmonary  or  cardiac  4.  Physical  examination  of  heart  and  lungs 
disease— moist  rales.  usually  negative. 

The  diagnosis  becomes  complete  if  the  characteristic  pain  points 
are  present,  with  prompt  aggravation  of  pain  soon  after  taking  food, 
vomiting  showing  hyperacidity,  hematemesis,  and  a  history  of 
chronic  trouble. 

The  blood  coming  from  the  stomach  does  not  necessarily  origi- 
nate from  an  ulcer.  One  may,  in  rar-e  instances,  be  called  upon  to 
exclude  carcinoma,  portal  vein  stasis  producing  passive  conges- 
tion, gastric  varicosities,  toxic  corrosions,  traumatisms,  scurvy,  acute 
yellow  atrophy  of  the  liver,  and  yellow  fever.  The  hemorrhages  of 
carcinoma  are  small  in  quantity  compared  to  those  of  ulcer,  and  in 
cancer  the  blood  is  more  frequently  decomposed  and  of  a  coffee-  or 
chocolate-brown    color,  and    there    are    rarely  any  bloody  stools. 


480  ULCER    OF    THE    STOMACH. 

Charcot  has  reported  hematemesis  in  hysteria  (crises  gastriques), 
but  Debove  suggests  {loc.  cit)  that  organic  and  functional  nervous 
diseases  may  be  coincident  with  ulcer.  In  sudden  gastric  hemor- 
rhages the  previous  history  will,  as  a  rule,  enable  one  to  distinguish 
between  the  above-mentioned  possibilities.  In  hemorrhage  from 
passive  congestion  due  to  stasis  of  the  portal  vein,  the  epigastric 
pain  is  very  slight  or  entirely  absent. 

Cholelithiasis  may  be  confounded  with  ulcer  when  there  has  been 
no  blood  in  the  vomit  or  stools,  nor  any  grit,  sand,  or  stones  in  the 
evacuations.  The  following  signs  and  symptoms  are  then  of  value. 
The  pain  in  hepatic  colic  is  not  in  connection  with  the  taking  in  of 
food ;  it  draws  from  the  median  line  to  the  right.  The  dorsal  pain 
point  of  ulcer  is  located  at  the  level  of  the  twelfth  thoracic  verte- 
bra, to  the  left  and  very  close  to  the  body  of  the  twelfth  vertebra. 
But  the  dorsal  pain  point  of  cholelithiasis  is  located  to  the  right, 
about  two  to  three  fingers'  breadths  from  the  twelfth  dorsal  or 
first  lumbar  vertebra.  In  ulcer  there  is  rarely  any  pain  on  the  right 
side;  even  if  there  is,  it  is  much  less  intense,  and  in  cholelithiasis 
there  is  rarely  any  pain  to  the  left  of  the  spinal  column. 

In  cholelithiasis  the  right  lobe  of  the  liver  and  the  gall- 
bladder is  enlarged  after  an  attack  ;  and  during  the  intervals  be- 
tween the  attacks  all  kinds  of  foods  can  be  eaten  with  impunity. 
In  cholelithiasis  the  amount  of  HCl  in  the  gastric  contents  is 
normal  or  subnormal,  or  the  contents  may  not  show  any  free 
HCl;  in  ulcer  there  is  hyperacidity.  Icterus,  when  repeatedly 
observed,  following  attacks  of  pain,  strengthens  the  diagnosis  of 
cholelithiasis,  but  it  must  be  emphasized  that  with  duodenal  ulcer 
icterus  is  occasionally  observed.  In  private  practice  we  have 
observed  two  cases  in  which  cholelithiasis  and  gastric  ulcer  occurred 
contemporaneously. 

Diagnosis  of  the  Couiplicatio7is  and  Consequences  of  Gastric  Ulcer. — 
These  are  :  (i)  The  perforation  peritonitis.  (2)  Cicatricial  stenosis  of 
the  pylorus.  (3)  The  transition  of  ulcer  into  carcinoma,  or  ulcus 
carcinomatosum.  (4)  Hour-glass  stomach  from  cicatricial  con- 
tractions. (5)  Subphrenic  abscess.  (6)  Progressive  pernicious 
anemia. 

The  diagnostic  signs  of  perforative  peritonitis  are:  {a)  great 
rigidity  of  the  abdominal  muscles,  flat  abdomen  ;  {b)  disappear- 
ance or  diminution  of  liver  dullness  ;  this  sign  may  be  absent,  how- 


SUBPHRENIC    ABSCESS.  48 1 

ever,  if  only  liquid  gastric  contents  and  no  air  escape  into  the 
peritoneum ;  (c)  vomiting.*  According  to  Rosenheim  {Zeitschr. 
f.klin.  Med.,  Bd.  xvii,  S.  116)  about  five  to  six  per  cent,  of  gas- 
tric ulcers  develop  carcinomata  at  their  margins,  and  these  carci- 
nomata  are  said  to  be  associated  with  a  pronounced  hyperacidity. 

The  so-called  hour-glass  stomach  may  be  produced  by  one  or 
more  cicatrices  in  the  neighborhood  of  the  antrum  pylori.  Cica- 
trices of  the  duodenum  may  cause  a  dilatation  beyond  the  pylorus, 
by  which  the  latter  will  itself  constitute  the  narrowing  or  isthmus 
of  what  very  much  resembles  an  hour-glass  stomach  (Reiche, 
"  Jahrb.  d.  Hamburger  Staatskrankenanstalt,"  1890,  p.  180). 

Subphrenic  Abscess  (Pyopneumothorax  subphrenicus). — In  1880, 
Leyden  first  described  a  combination  of  diseases  which  followed 
perforative  peritonitis  or  escape  of  pus  from  the  intestines  into 
the  peritoneum.  A  purulent  exudate  forms  in  the  lower  parts 
of  the  right  or  left  thoracic  cavity  under  symptoms  of  inflamma- 
tion, but  no  coughing  or  expectoration  is  connected  therewith. 
The  posterior  and  lower  thoracic  regions  give  dullness  on  percus- 
sion, absence  of  vesicular  murmur,  and  fremitus.  Metallic  sounds 
can  be  made  out  when  one  percusses  and  auscults  simultaneously. 
The  succussion  sound  is  distinct.  The  lung  is  distinctly  intact 
above  these  parts.  The  respiratory  murmur  is  vesicular  and  the 
fremitus  is  maintained  down  to  the  fourth  or  fifth  rib  ;  from  here  on 
the  respiratory  murmur  suddenly  ceases.  The  dullness  that  cor- 
responds to  the  exudate,  changes  with  various  positions  of  the 
body.  The  signs  of  equally  distributed  pressure  in  the  pleura  are 
wanting.  The  movements  of  the  corresponding  half  of  the  thorax 
are  not  co-ordinated,  the  intercostal  spaces  are  almost  obliterated, 
and  the  heart  is  slightly  pushed  to  the  other  side. 

If  the  exudate  is  on  the  right  side,  the  liver  projects  far  into  the 
abdomen,  and  can  be  felt  at  or  below  the  umbilicus.  The  exudate 
may  perforate  into  the  respiratory  passages  and  cause  sudden  and 
abundant  expectoration  of  foamy  pus  containing  hepatic  cells.     In 


*  The  diagnosis  of  perforation  has  been  attempted,  when  other  signs  failed,  by  punc- 
turing through  the  abdominal  walls  with  a  sterilized  hypodermic  needle,  when  the 
gaseous,  bacterial,  and  cellular  evidences  of  perforation  can  be  aspirated.  (Test  for 
H2S  by  lead-acetate  paper;  when  the  abdomen  is  very  tympanitic,  this  sign  is  almost 
pathognomonic.)  The  puncture  is  made  when  the  patient  is  in  the  dorsal  position.  The 
escaped  gases  will  rise  upward  between  the  intestines  and  the  peritoneal  wall.  There  is 
danger  of  puncturing  the  intestines  in  this  method. 
32 


482  ULCER    OF    THE    STOMACH. 

1894  Maydl  collected  179  cases  of  subphrenic  accumulations  of  pus. 
In  20  per  cent,  of  these  cases  perforating  ulcers  of  the  stomach  or 
duodenum  were  found  to  be  the  causes.  ("  Subphrenic  Abscess," 
Meltzer  in  the  A^.  V.  Med.  Joiir.,  June  24,1893.  Progressive  pernicious 
anemia  as  a  concomitant  phenomenon  of  ulcer  can  be  recognized 
by  the  reduction  of  the  number  of  red  corpuscles  and  the  appear- 
ance of  the  poikilocytes,  microcj'tes,  and  macrocytes.  (See  chapter 
on  The  Blood  in  Gastric  Diseases,  p.  376  et  seg.) 

Treatment  of  Gastric  Ulcer. — Prophylactic. — If  gastralgias  are 
frequent  in  a  person  afflicted  with  hyperacidity,  the  diet  must  be 
very  mild  and  unirritating  ;  two  weeks  of  a  milk  diet  will  be  the  safest. 
Sudden  deviations  in  the  temperature  of  the  food  must  be  avoided, 
daily  evacuations  must  be  effected  by  suitable  diet,  and,  if  need  be, 
Carlsbad  salts,  and  the  hyperacidity  remedied.  The  dietetic  and 
medicinal  treatment  will  vary  according  to  the  presence  or  absence 
of  hematemesis. 

Treatment  of  Hematemesis  and  the  Period  Immediately  Following 
It. — During  the  stages  of  blood  vomiting  the  patient  must  remain 
absolutely  quiet  in  bed  and  not  even  arise  for  urination  or  defeca- 
tion. Positively  nothing  should  be  permitted  by  the  mouth,  not 
even  ice.  If  the  patient  is  well  nourished  no  alimentation  by  the 
rectum  is  advisable,  because  this  necessarily  disturbs  the  rest  and 
compels  the  stomach  to  move  because  of  the  changes  in  position 
required.  If  the  patient  is  weak  and  anemic,  a  nourishing  enema 
may  be  imperatively  indicated  every  four  hours.  The  enema  most 
favored  is  that  of  Boas,  consisting  of  250  gm.  of  milk,  the  yolks  of 
two  eggs,  a  teaspoonful  of  salt,  one  ounce  of  good  claret  and  one 
tablespoonful  of  aleuronat  flour.  Previously  to  giving  an  enema  for 
nutritive  purposes,  the  rectum  and  colon  must  be  cleaned  by  a  high 
irrigation  with  one  liter  of  warm  water.  The  above  ingredients  are 
thoroughly  mixed  by  means  of  an  egg-beater,  warmed  to  about 
99°  F.,  and  permitted  to  run  in  under  gentle  pressure,  care  being 
taken  that  the  tube  is  introduced  as  far  up  into  the  sigmoid  flexure 
as  possible. 

When  the  hematemesis  is  copious  and  persistent,  a  hypodermic 
injection  of  ergotol,  20  to  30  minims,  should  be  given  at  once. 
With  this  preparation  of  ergot  we  have  had  extensive  experimental 
and  clinical  experience  (see  Med.  Nezvs  for  Jan.  3 1 ,  Feb.  7,  Mar.  7  and 
14,  1891,  "An  Experimental  and  Clinical  Study  of  Ergot,"byJ.  C. 
Hemmeter).     At  the  same   time  an  ice-bag  is  placed  over  the  epi- 


TREATMENT    OF    GASTRIC    ULCER.  483 

gastrium,  and  if  the  pain  is  severe  an  injection  of  ^  of  a  gr.  of 
morphin  should  not  be  delayed,  as  by  the  ease  and  quiet  it  brings 
about  this  drug  acts  as  an  adjuvant  to  the  hemostatic.  For  three 
days  following  hematemesis  this  treatment  should  not  be  changed, 
and  no  food  allowed  by  mouth.  The  treatment  from  the  fourth  to 
the  seventh  day  after,  consists  of  absolute  rest  in  bed,  a  wet  pack 
covered  with  oiled  silk  and  bandage  being  applied  to  the  epigastrium. 
And  now  one  may  resume  feeding  by  the  mouth,  but  in  form  of 
liquids  only, — half  milk,  half  lime-water,  or  milk  with  a  small  addi- 
tion of  coffee  or  tea,  never  more  than  lukewarm  ;  also  beef-tea,  to 
which  lactose,  meat  powder,  or  somatose  have  been  added,  and  egg- 
albumen  water.  Chocolate,  yolks  of  eggs,  and  all  alcoholic  beverages 
must  be  forbidden  in  this  stage. 

In  the  second  week  after  the  hemorrhage  a  typical  cure  for  ulcer, 
according  to  principles  laid  down  by  Wilson  Fox  ("  Diseases  of  the 
Stomach,"  1872,  p.  146),  v.  Leube  ("  Ziemssen's  Handbuch,"  Bd.  vii, 
2,  p.  120),  and  v.  Ziemssen  {Volkinaniis  Samniliing  klin.  V^ortrdge, 
No.  75),  should  be  instituted.  These  systematic  treatments  are  in 
the  main  rest-cures  combined  with  the  daily  use  of  a  glass  of  Carls- 
bad Miihlbrunnen  water,  liquid  or  semiliquid  diet,  and  hot 
applications  to  the  epigastrium.  Every  morning  the  patient  takes 
a  glass  of  (40°  R.)  warm  Miihlbrunnen  in  which  five  to  ten  gm.  of 
natural  or  artificial  Carlsbad  salts  have  been  dissolved.  Spongiopi- 
lin  cut  into  any  requisite  shape  and  dipped  into  hot  water,  is  applied 
externally  to  the  epigastrium,  and  renewed  every  three  hours  night 
or  day.  The  diet  consists  mainly  of  milk  and  whipped  eggs;  if  there 
is  great  weakness,  the  above  enemata,  containing  perhaps  two  ounces 
of  claret,  should  be  given,  and  if  the  pulse  is  feeble,  hypodermic 
injections  of  digitalin  -^-^  of  a  gr.,  and  strychnia  -gig-  of  a  gr.  In  one 
case  of  profuse  hematemesis  we  gave  an  intravenous  injection  of 
500  c.c.  of  sterilized  normal  salt  solution.  The  pulse  had  left  the 
wrist,  and  was  barely  perceptible  at  the  carotid  ;  the  effect  was 
prompt,  and  the  opinion  of  the  assisting  colleagues  was  that  life 
was  saved  thereby, — the  case  recovering  later  on  under  the  nitrate 
of  silver  treatment. 

In  the  third  week,  when  the  pain  in  the  epigastrium  and  general 
cardialgia  have  ceased,  the  patient  may  be  permitted  to  rest  on  the 
sofa,  and  the  Carlsbad  water  is  continued.  We  might  remark  here 
that  the  Saratoga  Carlsbad  and  the  Hathorn  spring  waters  act  quite 
as  well  as  the  imported.     In  fact,  the  only  objects  of  the  Carlsbad 


484  ULCER    OF    THE    STOMACH. 

water  in  the  cures  of  Leube  and  Ziemssen  are  the  neutrahzation 
of  the  hyperacidity  and  the  promotion  of  intestinal  evacuation. 
One  must  not  gain  the  impression  that  Carlsbad  waters  or  salts  have 
any  direct  or  specific  curative  effect.  Ewald  {loc.  cit.,  p.  275)  de- 
clares that  many  a  patient  who  went  to  Carlsbad  might  have 
recovered  more  rapidly  if  he  had  taken  the  rest-cure  at  home.  To 
neutralize  the  hyperacidity  and  prevent  autodigestion  we  usually 
give  the  following : 

IJ .      Magnesiee  ustse, 
Sodii  carbonatis, 

Potassii  carbonatis,     ....       aa  .    .    .    .     5.0  ^j    -j-  grs.  xv 

Sacchar.  lactis, 25.0  5  vj  -J-  grs.  xx. 

SiG. — Haifa  teaspoonful  dry  on  the  tongue  every  three  hours. 

In  the  third  week  one  may  permit  dipped  cakes,  toast  or  Zwie- 
back ;  broiled  sweetbread  or  calf's  brain,  dumplings  made  of  finely 
divided  meat,  broiled  pike,  bluefish,  trout,  oysters,  in  very  small 
quantities.  In  the  fourth  week  purees  made  of  potatoes,  peas,  or 
beans  rubbed  through  a  sieve,  stewed  apples,  pears,  and  plums. 
Saratoga  Vichy  may  be  allowed ;  all  vegetables  that  can  be 
prepared  in  puree  (gruel)  form,  such  as  spinach,  carrots,  peas,  etc., 
etc.  For  many  years  the  patient  must  avoid  raw  fruits,  all  sour, 
acid,  or  spiced  food  and  drink,  ice  cream  and  all  cold  and  hot 
beverages.  If  there  has  been  no  hematemesis  the  treatment  had 
best  be  carried  out  along  these  lines  also.  On  pages  232,  233, 
and  235  detailed  diet  lists  for  cases  of  gastric  ulcer  are  given. 
In  rebellious  cases  of  recurrent  gastralgias,  vomiting,  and  hyper- 
acidity, McCall  Anderson  {Brit.  Med.  Jour.,  1890,  May  10)  and 
H.  B.  Donkin  {TJie  Lancet,  Sept.  27,  1890)  recommend  a  total 
abstinence  cure  of  two  to  three  weeks,  during  which  the  patients 
are  fed  exclusively  by  rectal  enemata  (three  to  four  in  the  day) ;  hot 
applications  to  the  epigastrium  are  also  used.  After  ten  days  of 
rectal  feeding  they  cautiously  and  slowly  return  to  feeding  by  the 
mouth  (milk,  bouillon,  egg-albumen).  We  have  tried  this  in  a 
number  of  cases  in  which  relapses  had  occurred  after  the  rest-cure, 
and  can  speak  in  favor  of  the  method.  Gerhardt  and  Boas  speak 
very  favorably  of  nitrate  of  silver  in  light  cases  of  gastric  ulcer. 
The  latter  begins  with :  !^«.  Argenti  nitratis  0.25  to  1 20  of  peppermint 
water;  one  tablespoonful  three  times  a  day  on  an  empty  stomach. 
Then  the  dose  is  increased  to  0.3  to  120  of  water,  of  which  two 
bottles  are  taken,  and  finally  0.4  to  120  of  water,  of  which  also  two 


SURGICAL    TREATiMENT    OF    GASTRIC    ULCER.  485 

bottles  are  advised.     This  is  combined  with  a  sparing  diet  and  as 
much  rest  as  possible. 

Fleiner  and  Kussmaul  recommend  bismuth  subnitrate  in  all 
irritative  conditions  of  the  gastric  mucosa — old  ulcers,  erosions, 
excoriating  carcinomata.  Fleiner  employs  it  in  the  following 
manner:  lO  to  20  gm.  (150  to  300  grs.)  of  bismuth  subnitrate  are 
stirred  in  200  c.c.  of  warm  water ;  after  the  stomach  has  been 
thoroughly  cleansed  by  lavage,  this  suspension  is  poured  into  the 
stomach  and  allowed  to  remain  three  minutes ;  then  the  clear 
water  is  siphoned  out,  the  bismuth  remaining  behind  and  form- 
ing a  coating  to  the  injured  places  in  the  stomach.  It  is  a  modified 
direct  or  local  treatment.  We  usually  employ  three  drams  of 
bismuth  subnitrate  and  one  dram  of  bismuth  subgallate  in  a  pint 
of  warm  water,  having  previously  thoroughly  cleansed  the  stomach 
with  solutions  of  sodium  bicarbonate  (Sss  to  a  pint),  the  state  of 
the  ulcer  permitting. 

In  chronic  cases  in  which  Fleiner's  treatment  can  be  employed  it 
relieves  pain  promptly,  reduces  the  hyperacidity,  and  promotes 
healing;  it  is  worth  trying  in  cases  of  long  standing.  Director 
local  treatment  of  this  kind  is  permissible  when  there  have  been  no 
hemorrhages  or  tarry  stools  for  one  month.  During  this  time  the 
ordinary  cures  by  diet,  rest,  Carlsbad  Miihlbrunnen,  etc.,  must  have 
been  employed.  There  must  be  no  sensitiveness  to  pressure  on 
the  epigastrium.  Chronic  ulcers  that  have  resisted  dietetic  and 
medicinal  treatment,  have  been  successfully  treated  by  this  method 
by  Mathes  {loc.  cit.),  O.  Fischer  {loc.  at.),  and  Stintzing  {loc.  cit).  The 
anemia  following  ulcer  may  require  iron,  arsenic,  strychnin.  Iron 
preparations  must  contain  no  acid. 

Surgical  treatment  becomes  necessary  when,  after  a  trial  of  the 
aforesaid  methods,  the  ulcer  or  ulcers  prove  very  obstinate  and 
not  amenable  to  medical  treatment,  or  because  hemorrhages  may 
become  so  abundant  and  frequent  as  to  endanger  life,  or,  lastly, 
because  of  perforation.  Nelson  C.  Dobson  {Bristol  Medical  and 
Snrg.  Jonr.,  1883)  first  advocated  surgical  interference  for  perforat- 
ing gastric  ulcer.  In  this  country,  Robert  F.  Weir,  of  New  York, 
has  contributed  the  most  important  work  to  this  domain  of  sur- 
gery. His  last  important  paper  (Robt.  F.  Weir  and  E.  M.  Foote, 
"  The  Surgical  Treatment  of  Round  Ulcer  of  the  Stomach  and  Its 
Sequelae,"  etc.,  Medical  Nezvs,  April  25  and  May  2,  1896)  contains 
an  account  of  72  cases  of  laparotomy  for  acute  perforation  of  gas- 
tric ulcer. 


486  ULCER    OF    THE    STOMACH. 

Gastric  ulcers  have  been  excised  entirely,  the  sequels  thereof 
have  been  removed  by  the  severing  of  peritonitic  adhesions,  and 
hour-glass  stomach  much  improved  by  gastro-anastomosis  (see  von 
Hacker,  "  Ueber  Magenoperationen  bei  Carcinom  u.  b.  narbigen 
Stenosen,"  published  by  Wilh.  Braumiiller,  Wien  and  Leipzig, 
1895). 

For  further  details  concerning  the  operations  on  the  stomach  for 
recent  ulcers  and  for  cicatrices,  we  refer  to  the  sections  on  Sur- 
gery of  the  Stomach. 

Treatment  of  Exlimistive  Gastric  Hemorrhage  by  Transfusion  and 
Intravenons  Injection  of  Normal  Salt  Solution. — Michel  transfused 
successfully  in  a  case  of  extreme  anemia  following  gastrorrhagia 
{Bcrl.  klin.  Wochenschr.,  1870,  No.  49).  In  a  case  of  profuse  and 
repeated  hematemesis,  which  followed  washing  out  the  stomach, 
Michaelis  infused  into  the  veins  350  c.c.  of  solution  of  common  salt. 
Reaction  gradually  followed,  and  the  patient  recovered.  This  case, 
which  was  one  of  probable  ulcer,  illustrates  the  advantages  of  infus- 
ing a  small  quantity  {ibid.,  June  23,  1884).  The  sudden  infusion  of 
quantities  of  liquid  exceeding  500  c.c.  will  cause  such  an  abrupt  rise 
in  arterial  pressure  that  the  injured  blood-vessels  in  the  gastric 
mucosa  may  reopen,  causing  renewed  profuse  hemorrhages.  The 
dangers  are  illustrated  by  a  case  reported  by  von  Hacker,  who 
infused  1500  c.c.  of  salt  solution  into  a  patient  in  a  state  of  extreme 
collapse  resulting  from  hemorrhage  from  gastric  ulcer.  The  patient 
rallied,  but  he  died  three  hours  after  the  infusion  from  renewed 
hemorrhage  {Wiener  vied.  Wochenschr.,  1883,  No.  37).  In  Legroux's 
case  of  gastric  ulcer,  renewed  hemorrhage  and  death  followed  the 
transfusion  of  only  80  gm.  of  blood  {Arch.  Gen.  de  Med.,  Nov., 
1880).  In  a  case  quoted  by  Roussel,  Leroy  transfused  130  gm.  of 
blood  into  a  girl  twenty  years  old,  who  lay  at  the  point  of  death 
from  repeated  hemorrhages  from  a  gastric  ulcer.  In  the  following 
night  renewed  hemorrhage  and  death  occurred  {Gaz.  des  Hop., 
Sept.  22,  1883).  According  to  the  experiments  of  Schwartz  and 
Ott,  the  transfusion,  or,  rather,  infusion,  of  physiological  salt 
solution  is  as  useful  as  that  of  blood,  and  it  is  simpler  and  unat- 
tended with  some  of  the  dangers  of  blood  transfusion.  The 
formula  is  chlorid  of  sodium,  6  parts  ;  distilled  water,  looo.  Our 
personal  experience  is  confirmatory  of  the  observations  of  these 
last-mentioned  experimenters. 

Fleiner  {loc.  cit.)  favors  the  excision  of  simple  gastric  ulcer,  when 


LITERATURE    ON    ULCER    OF    THE    STOMACH.  487 

external  (social)  conditions  render   a  suitable   diet  and  treatment, 

impossible.     We  can  not  advocate  this  heroic  treatment  for  simple 

uncomplicated  ulcer,  feeling  convinced  that  the  various  treatments 

with  which  we  are  now  acquainted  are  eminently  successful.     But 

if  a  laparotomy  has  been  undertaken   and  the  stomach  has  been 

opened  for  other  indications  (suspicion  of  peritonitis,  perigastritis, 

carcinoma,  perforation),  and  an  uncomplicated  ulcer  is  discovered, 

the  excision  of  the  latter  is  undoubtedly  justifiable,  and  has  been 

successfully  carried  out  by  Cordua,  Kansche,  Maurer  (at  Czerny's 

Clinic),  and  Mintz  {loc.  cit^.    In  the  latter  case  the  gastric  functions 

were  entirely  recovered.     Extreme  and  persistent  gastric  pain  has 

been  the  indication  for  gastro-enterostomy  in  a  case  of  Cahn's  {Joe. 

cit.). 

LITERATURE  ON  ULCER  OF  THE  STOMACH. 

IN   ADDITION   TO   THE   TEXT-BOOKS    MENTIONED    IN   THE    LITERATURE 
ON    GASTRITIS. 

1.  Cruveilhier,  "  Anatomia  Pathologique,"  1829-1835,  Livraison  X. 

2.  W.  Brinton  [loc.  cii.). 

3.  C.  A.  Ewald  {loc.  cit.),  p.  234.     "  Diseases  of  the  Stomach,"  p.  233. 

4.  \'on  Sohlern,  "  Der    Einfluss  der  Ernahrung  auf  die  Entstehung  des 
Magengeschwiirs,"  Berl.kliti.  Wochenschr.,  1889,  No.  14. 

5.  Griffini  ,und  Vassale,  "  Beitrage  zur  patholog.  Anat.,"  von  Ziegler  und 
Nauwerck,  Bd.  iii,  Heft  5,  p.  425. 

6.  Oaincke   und  Daettwyler,  Correspondenzbl.  f.   Schweizer  Aerzte,  1875, 
p.  loi. 

7.  C.  A.  Ewald,  "  Klinik  der  Verdauungskrankheiten,"  i.  Theil,  3.  Aufl., 
p.  122. 

8.  Silbermann,  Deutsche  7ned.  Wochenschr.,  1886,  No.  29. 

9.  Marcet,  "  Medico-Chirurgical  Transactions,"  vol.  xii,  p.  72. 

10.  O.  Harttung,  "  L'eber  Faltenblutungen  und  hamorrhagische  Erosionen," 
Deutsche  med.  Wochenschr.,  1890,  No.  38,  p.  847. 

11.  Rokitansky,  "  Lehrbuch  der  patholog.  Anatomie." 

12.  Rindfleisch,  "  Lehrbuch  der  patholog.  Anatomie." 

13.  Axel  Key,  Gurlt-Virchow's  Jahresb.,  1871. 

14.  Langerhans,   Virchoiv  s  Arch.,  Bd.  cxxiv,  p.  373. 

15.  Max  Einhorn,  Medical  Record,  June  23,  1894. 

16.  R.  Virchow,   Virchoiv' s  Archiv,  Bd.  v,  p.  363. 

17.  Panum,  "  Experimentelle  Beitrage  zur  Lehre  von    der  Embolic,"   Vir- 
chow's  Archiv,  Bd.  xxv,  1862. 

iS.  Pavy,  "On  Gastric  Erosion,"  Guy  s  Hospital  Reports,  vol.  xiv,  1868. 

19.  Wilson  Fox,  "  The  Diseases  of  the  Stomach,"  1872,  p.  146. 

20.  F.  Riegel,   Zeitschr.  f.   klin.  Med.,  Bd.   xil,  p.  434,  and  Deutsche  med. 
Wochenschr.,  1886,  No.  52. 

21    Jaworski    und    Korczynski,    Deutsche    med.     Wochenschr.,    1886,    Nos. 
47-49- 


488  ULCER    OF    THE    STOMACH. 

22.  Chas.  G.  Stockton,"  The  Etiology  of  Gastric  Ulcer,"  The  Medical  News, 
January  14,  1893. 

23.  Th.  Rosenheim,  "  Pathologie  und  Therapie  der  Krankheiten  der  Speise- 
rohre  und  des  Magens,"  Wien  und  Leipzig,  1891,  p.  161. 

24.  Debove  et  Remond,  "  Traite  des  Maladies  de  I'Estomac,"  Paris,  p.  255. 
35.  Nolte,  see  Ewald  {loc.  cit.,  239). 

26.  Welch,  cited  from  Osier's  "  Practice  of  Medicine,"  p.  369. 

27.  Anderson,  British  Medical  Journal,  May  10,  1890. 

28.  E.  Leyden,  "  Ueber  Pyopneumothorax  subphrenicus  und  subphrenische 
Abscesse,"  Zeitschr.f.  klin.  Med.,  1880,  p.  320. 

29.  Pfuhl,  Berliner  klin.  IVochettschrift,  1877,  p.  57. 

30.  C.  Beck,  Medical  Record,  February  15,  1896. 

31.  Th.  Rosenheim,  "  Zur  Kenntniss  des  mit  Krebs  complicirten  runden 
Magengeschwiirs,"  Zeitschr.f.  klin.  Med.,  Bd.  xvii,  p.  116. 

31  a.  Th.  Rosenheim,  Deutsche  med.  Wochenschr.,  1890,  No.  15. 

32.  Fleiner,  "  Verhandl.  des  XII.  Congresses  f.  innere  Medicin,"  1893  ;  also 
Volkinann  s  Vortr'dge,  No.  103. 

33.  Rosenheim,  "Die  neueren  Behandlungsmethoden  des  Magens,"  Ber- 
liner Klinik,  May,  1894. 

34.  Barling,  Birmingham  Medical  Review,  August,  1895. 

35.  Dobson,  Bristol  Medical  and  Surgical  Journal,  1893,  p.  196. 

36.  Robert  F.  Weir  and  E.  M.  Foote,  "The  Surgical  Treatment  of  Round 
Ulcer  of  the  Stomach  and  Its  Sequelae,  with  an  Account  of  Case  Successfully 
Treated  by  Laparotomy,"  Medical  News,  April  25  and  May  2,  1896. 

37.  A.  Landerer  und  G.  Glucksmann,  "  Mittheilungen  aus  den  Grenzgebieten 
der  Medizin  und  Chirurgie,"  Bd.  I,  p.  168,  Jena,  1896. 

38.  Lauenstein,  Arch.f.  klin.  Chirurgie,  vol.  xiv. 

(We  refer  also  to  "  Literature  on  Gastric  Ulcer  "  in  William  H.  Welch's 
article  in  "American  System  of  Medicine,"  vol.  11,  p.  480,  in  which  over  140 
important  bibliographical  references  are  given.) 

In  the  fourth  volume  of  Penzoldt  and  Stintzing's  "  Handbuch  d. 
speciellen  Therapie,"  vol.  IV,  pp.  316,  317,  also  pp.  437  and  438,  are  contained 
150  bibliographical  references  on  the  treatment  of  Gastric  Ulcer. 

39.  A.  Bottcher,  "ZurGenese  des  perforirenden  Magengeschwiirs,"  Dorpat. 
med.  Zeitschr.,  1874. 

40.  Bohland,  "  Ueber  die  Hernia  epigastrica  und  ihre  Folgezustande,"  Berl. 
klin.  Wochenschr.,  1894,  No.  34. 

41.  Caro,  "  Ueber  Blutungen  aus  Oesophagusvariceen."  Diss.  Wiirzburg- 
Heidelberg,  1896. 

42.  Cramer,  "Ueber  die  Behandlung  des  Ulc.  ventr.  mit  grossen  Wismuth- 
dosen,"  Milnchener  med.  Wochenschr.,  1896,  No.  25. 

43.  Decker,  "  Exp.  Beitrag  zur  Aetiologie  der  Magengeschwiire,"  Berl.  klin. 
Wochenschr.,  1887. 

44.  Wilh.  Ebstein,  "  Experimentelle  Untersuchungen  liber  das  Zustande- 
kommen  von  Blutextravasaten  in  der  Magenschleimhaut,"  Arch.  f.  exp. 
Pathologic  u.  Pharm.,  11,  1878. 

45.  Wilh.  Ebstein,  "Ueber  die  Beziehungen  zwischen  Trauma  und  Magen- 
erkrankung,"  Deutsches  Arch.f.  klin.  Med.,  Bd.  Liv. 


LITERATURE    ON    ULCER    OF    THE    STOMACH.  489 

46.  ELasser,"  Die  Magenerweichung  der  Sauglinge,"  Stuttgart  und  Tubin- 
gen, 1846. 

47.  Griffini  u.  Vassale,  "  Ueber  die  Reproduction  der  Magenschleimhaut," 
Ziegler's  Beitiiige,  ill. 

48.  Giinzburg,  "  Zur  Kritik  des  Magengeschwiirs,"  Arch,  fiir  physiol.  Heil- 
kunde,  IX. 

49.  Hauser,  "  Das  chronische  Magengeschwiir,"  Leipzig,  1883. 

50.  Hoffmann,  "  Ueber  die  Erweichung  und  den  Durchbruch  derSpeiserohre 
und  des  Magens,"   Vtrchoius  Arckiv,  Bd.  XLiv. 

51.  Horner,  "  Cardialgie  durch  Einklemmung  praeperitonealer  Lipome," 
Prager  nied.  IVockejischr.,  1892. 

52.  Liebermeister,  "Ueber  das  einfache  Magengeschwiir,"  Volkmann  s 
Sammlung  klin.   Vortrdge,  1892,  No.  61. 

53.  Litten,  "Ulcus  ventriculi  tuberculosum,"   Virchow's  Arch.,  Bd.  Lxvil. 

54.  Marchand,  "  Gastromalacie  (und  Oesophagomalacie),"  "  Real-Ency- 
klopadie,"  xii. 

55.  Matthes,  "  Ueber  den  Vorschlag  Kleiner's,  Reizerscheinungen  des 
Magens  mit  grossen  Dosen  Wismuth  zu  behandeln,"  Centf'alblatt filr  innere 
Med.,  1894. 

56.  W.  Mayer,  "  Gastromalacia  ante  mortem,"  Deutsches  Arch,  fur  klm. 
Med.,  IX,  1872. 

57.  Mintz,  "Operative  Behandlung  der  Magenkrankheiten,"  Zeitschr.  f. 
klin.  Med.,  Bd.  xxv,  1894. 

58.  L.  Miiller,  "  Das  corrosive  Geschwur  im  Magendarmkanal,"  Erlangen, 
i860. 

59.  C.  Neuwerck,"  Ueber  den  mycotischen  Ursprung  des  peptischen  Magen- 
geschwiirs," il/zV«^^^«^r  ;;i^(/.  Wochefischr.,  i8gS- 

60.  V.  Noorden,  "  Magensaftsecretion  und  Blutalkalescenz,"  Arch,  fur  exp. 
Pathologie  u.  Pharin. 

61.  Nissen,  "Zur  Frage  der  Indication  der  operativen  Behandlung  des 
runden  Magengeschwiirs,"  Petersburger  vied.  Wochenschr.,  1890. 

62.  Openchowski,  "Zur  pathologischen  Anatomieder  geschwiirigen  Processe 
im  Magendarmtractus,"  Virchoiv  s  Arch.,  Bd.  cxvii. 

63.  Quincke,  "  Die  Entstehung  des  Magengeschwiirs,"  Deutsche  med. 
Wochenschrift,  1882. 

64.  Rasmussen,"  Ueber  die  Magenschniirfurche  und  die  Ursache  des  chro- 
nischen  Magengeschwiirs,"  CeJitralblatt fur  die  med.  Wissenschaften,  1887. 

65.  Ritter,  "  Ueber  den  Einfluss  von  Traumen  auf  die  Entstehung  des 
Magengeschwiirs,"  Zeitschr.  f.  klin.  Med.,  xii. 

66.  Saundby,  "  Ein  Fall  von  sanduhrformiger  Einschniirung  des  Magens 
in  Verbindung  mit  einem  kolossalen  Magengeschwiir,"  Deutsche  fned.  Woch- 
enschr., 1 89 1. 

67.  Savelieff,  "  Ueber  die  Wismuthbehandlung  des  runden  Magenge- 
schwiirs," Therap.  Monatshefte,  1894,  No.  10. 

68.  Schiff,  "  Beitrag  zur  Kenntniss  des  motorischen  Einflusses  der  im  Seh- 
hiigel  vereinigten  Gebilde,"  Arch.  f.  physiol.  Heilkunde,  v,  1846. 

69.  Schiff,  "  Ueber  die  Gefassnerven  des  Magens,"  ibid.,  xiii,  1854,  S.  30. 

70.  Sehrwald,"  Was  verhindert  die  Selbstverdauung  des  lebenden  Magens? 


490  ULCER    OF    THE    STOMACH. 

Ein  Beitrag  zur  Aetiologie  des  runden  Magengeschwiirs,"  Miinchener  med. 
Wochenschr.,  1888. 

71.  Stepp,    "Zur    Behandlung  des    chronischen    Magengeschwiirs,"    Ver- 
handlungen  der  65.  Versammlung  deutscher  Naturforscher  und  Aerzte,  1893. 

72.  Sticker,  "  Ueber  den  Einfluss  der  Magensaftabsonderung  auf  den  Chlor- 
gehalt  des  Harns,"  Berl.  klin.  VVochenschr.,  1887. 

73.  Sticker  und  Hubner,  "  Wechselbeziehungen  zwischen  Secreten  und  Ex- 
creten,"  Zeitschr.f.  klin.  Med.,  xii,  1887. 

74.  Talma,  "  Untersuchungen  liber  Ulc.  ventr.   simpl.   Gastromalacie  und 
Ileus,"  Zeitschrift f.  klin.  Med.,  xvil,  1890. 

75.  Thorspecken,"  Ein  Fall  von  Magenerweichung  ante  mortem,"  Deutsches 
Arch.f.  klin.  Med.,  xxxiii. 

76.  Welti,  "  Drei  Falle  von  Verbrennungstod,"  Cetiiralblatt fiir  allg.  Path., 
1890. 

"]"] .  Ziemssen,  "  Ueber   die   Behandlung  des  einfachen  Magengeschwiirs," 
Volkmanns  Sammlung  klinischer  Vortrdge,  1871,  No.  15. 

78.  R.  F.  C.  Leith,  Edinburgh  Hospital  Reports,   1894,  vol.  11,  pp.  198-238. 

79.  J.  O.  k^QcV,  Edinburgh  Hospital  Reports,  1894,  vol.  11. 

80.  O.  Fischer,  "Bismuth  Treatment."     Dissertation.     Jena,  1893. 

81.  Mintz,  "  Operat.  Behandl.  d.  Magenkrankh.,"  Zeitschr.  f.   klin.  Med., 
Bd.  XXV,  1894. 

82.  Cahn,  Berlin,  klin.  Wochetischr.,  1894,  No.  28. 

BIBLIOGRAPHY  OF  ULCUS  CARCINOMATOSUM. 

1.  Boas,  "  Diagnostik  u.  Therapie  d.  Magenkrankh.,"  p.  8. 

2.  Dittrich,  Prager  Vierteljahresschrift,  v,  1848,  S.  i. 

3.  Langguth,  Archiv f.  Verdamingskrankh.,  von  Boas,  Bd.  I,  S.  355,  "On 
Significance  of  Lactic  Acid." 

4.  Feierlag,  Inaug.-Diss.,  Dorpat,  1894. 

5.  Hauser,  "  Das  chronische  Magensgeschwiir,"  Leipzig,  1883. 

6.  Kollmann,    "Zur  Differentialdiagnose    zwischen    Magengeschwiir   und 
Magenkrebs,"  Berhti.  klin.  Wochenschr.,  1891,  Nos.  5,  6. 

7.  Oppler  und  Boas,  "  Zur  Kenntniss  d.  Mageninhalts  b.  Carcinome,"  etc., 
Deutsche  med.  Wochenschr.,  1895,  No.  5. 

8.  F.  Riegel,  "  Die   Erkrankungen  d.  Magens,"  p.    174.     (On  the  Oppler- 
Boas  bacillus.) 

9.  Rosenheim,  "  Zur  Kenntniss  desmit  Krebs  complicirten  runden  Magen- 
geschwiirs," Zeitschr.f.  klin.  Med.,  Bd.  xvii,  S.  116. 

10.  Rokitansky,  "  Lehrbuch  d.  patholog.  Anatomie,"  third  edition. 

11.  Schlesinger  und  Kaufmann,   Wieti.  klin.  RuJtdschaic,  1895,  No.  15.    (On 
the  Oppler-Boas  bacillus.) 

12.  Eisenlohr,  Deutsche  med.  Wochenschr.,  1890,  No.  52. 

13.  Biach,  Wien.ined.  Presse,  1890,  No.  3. 

14.  Tapret,  U?tion  Medic,  1891,  No.  98. 

15.  Pignal,  These  de  Lyon,  1891  (two  cases). 

16.  R.  Koch,  St.  Petersbtirger  med.  Wochenschr.,  1893,  No.  43. 

17.  Bouveret,  "Traite  de  Malad.  de  I'Estomac,"  Paris,  1893,  p.  274  (three 
cases). 


LITERATURE    ON    ULCER    OF    THE    STOMACH.  49 1 

18.  Lebert,  "  Die  Krankheiten  d.  Magens,"  Tubingen,  1878,  S.  440. 

19.  Brinton,  "  Lectures  on  Diseases  of  the  Stomach,"  London,  1864. 

20.  Leube,  "  Ziemssen's  Handbuch,"  Bd.  vii,  S.  124. 

21.  Ewald,  Klinik  d.   Verdatiungskrankh.,  1885. 

22.  C.  Meyer,  Inaug.-Dissert.,  Heidelberg,  1888. 

23.  Heitler,  Wien.  med.  Wochenschr.,  1883,  No.  31. 

24.  Krukenberg,  Inaug.-Dissert.,  Heidelberg,  1888. 

25.  Thiersch,  Milnch.  7ned.  IVochenschr.,  1886,  No.  13. 
26    Waltzoldt,  Charite-Ajinalen ,  Bd.  xiv. 

27.  Kulcke,  Inaug.-Dissert.,  Berlin,  1889. 

28.  Sticker,  "  \''erhandl.  d.  Congresses  f.  innere  Med.,"  1887. 

29.  Plange,  Inaug.-Dissert.,  Berlin,  1859. 

30.  Berthold,  Inaug.-Dissert.,  Berlin,  1883. 

31.  Steiner,  Inaug.-Dissert.,  Berlin,  1868. 

32.  Wollmann,  Inaug.-Dissert.,  1868. 


CHAPTER  IV. 

MALIGNANT  TUMORS  OF  THE  STOMACH. 

(A)  CARCINOMATA. 

Pathology. — Orth  distinguishes  four  forms  : 

1.  The  cylindrical  cell,  or  adenocarcinoma. 

2.  The  soft  glandular,  or  medullary  carcinoma. 

3.  The  hard  glandular  carcinoma,  or  scirrhus. 

4.  The  mucous,  or  colloid  carcinoma. 

In  the  section  on  the  Surgical  Operations  on  the  Stomach,  we 
have  spoken  of  the  relative  frequency  with  which  these  various 
types  of  carcinoma  attack  this  organ.  It  is  an  error  for  clinicians 
to  speak  of  gastric  cancer  as  if  this  were  the  only  type  of  malig- 
nant neoplasm  that  can  attack  the  stomach.  Inasmuch  as  these 
various  types  show  different  rates  of  mortality  after  operation,  and  as 
they  can  occasionally  be  distinguished  clinically  by  small  bits  of  the 
new  growth,  which  come  up  in  the  wash-water  or  are  found  caught  in 
the  eyes  of  the  stomach-tube,  it  is  essential  that  a  brief  pathological 
description  of  them  should  be  given.  The  types  which  we  have 
mentioned  are  not  sharply  distinguished  from  each  other,  but 
many  gradations  and  transitions  exist  between  them.  The  struc- 
ture of  a  gastric  malignant  neoplasm  is  by  no  means  a  matter  of 
indifference,  both  for  the  clinical  history  and  the  prospective  surgical 
treatment.  The  scirrhus  exhibits  the  most  protracted  course  ;  the 
medullary  (soft  glandular)  a  disposition  to  disintegration  and  for- 
mation of  metastases  ;  while  the  colloid  has  a  tendency  to  extend 
to  the  peritoneum,  and  rarely  forms  metastases. 

The  cyliiidrical  cell,  or  adenocarcinoma,  presents  a  soft,  dis- 
tinct prominence,  or  tumor,  upon  the  surface  of  which  smaller 
fungoid  elevations  develop,  being  attached  to  the  fundamental  tumor 
by  broad  or  narrow  bases,  which  give  the  surface  a  papillary  ap- 
pearance. In  this  case  the  tumor  regularly  has  a  red  color,  because 
each  individual  fungosity  contains  a  small  loop  of  blood-vessels. 
The  little  vessels  in  the  outer,  as  well  as  those  in  the  inner,  sections 
of  the  neoplasm  frequently   show  an   irregular   spindle-shaped  or 

492 


ADENOCARCINOMA    OF    THE    STOMACH.  493 

spherical  dilatation,  so  that  this  form  of  carcinoma  has  been  called 
by  Orth,  telangiectatic.  This  condition  of  the  blood-vessels  may 
explain  why,  in  this  type  of  cancer,  smaller  or  larger  extravasations 


Fig.  35. — Cancerous  Invasion  of  the  Glandular  Layer.    A   Portion  of  the  Mucous  Coat. 

Objective,  one-sixth.     Eyepiece,  one   inch.     X  about  320   diameters.     Stained  with  hematoxylin  and 

orange  G. 

This  cut  shows  very  well  the  small,  round-cell  infiltration  between  the  cross-sections  of  the  gastric 
tubules,  with  here  and  there  the  cells  very  much  crowded,  A,  A. 

The  exfoliation  of  the  cells  lining  some  of  the  glandular  acini  is  also  shown  in  places,  B. 

At  one  or  two  places  the  proliferation  of  the  epithelial  cells  that  line  the  glands,  with  breaking  of 
these  glandular  structures  and  the  escape  of  some  of  the  cells  into  the  surrounding  tissue,  is  seen,   C,  C,  C. 

The  entire  obliteration  of  some  of  the  glandular  structures  by  masses  of  cancer  cells,  £>,  D,  which  in 
many  places  are  strung  out  for  some  distance,  £,  E,  and  in  a  few  others  have  taken  on  the  pseudo- 
glandular  arrangement,  F,  is  also  well  shown. 

of  blood  are  found  on  the  surface,  as  well  as  in  the  parenchyma; 
and  also  accounts  for  the  frequent  effusion  of  blood  into  the  cavity 
of  the  stomach.     On  section,  the  so-called  "carcinoma  juice  "  ap- 


494 


MALIGNANT    TUMORS    OF   THE    STOMACH. 


pears  abundantly  on  the  surface,  and  in  this  "juice"  typical  cylin- 
drical cells  are  generally  exclusively  found  in  sections  examined 
microscopically.  Such  sections  present  varying  pictures,  accord- 
ing to  whether  they  are  taken  from    the   surface   or  from  deeper 


C 


,. •,^'>    -..«'.••'/*»'  -  .1..'.-:  la^i)  .<3S'S:i>»,.-* 


•■■•v'iS^-^^'  ■'^''•'^--•■••i'S^i 


Fig.  36. — Cancerous  Infiltration  of  the  Muscularis.     Section  of  a  Portion  of  the  Mus- 
cular Coat  of  the  Stomach. 

Objective,  one-sixth.     Eyepiece,  one  inch.     Stain,  hematoxylin  and  orange  G.     X  about  320  diameters. 

Cross-section  of  bundles  of  muscle-fibers  from  the  muscular  coat  are  shown,  A,  between  which  there 
are  a  large  number  of  small  round  cells,  B,  B,  in  places,  and  here  and  there  large  clumps  of  cancer 
cells,  C,  C,  C,  C,  a  few  of  which  show  the  attempt  at  pseudoglandular  formation,  £),  D,  in  some 
instances  arranging  themselves  in  complete  circles,  while  in  others  only  a  portion  of  an  acinus  is  formed. 

regions  of  the  neoplasm.  On  the  surface  the  aspect  closely  re- 
sembles that  of  a  papillary  fibroma,  but  in  the  deeper  regions 
a  glandular  structure  becomes   very  distinct,  for  here    cylindrical 


MEDULLARY    CARCINOMA.  495 

cells  may  be  seen  lining  tubular,  hollow  spaces  in  a  regular  man- 
ner, these  tubular  ducts  being  separated  by  connective  tissue,  which 
generally  shows  small-celled  infiltration  ;  nor  are  these  glandular 
hollow  spaces  always  regular  in  distribution  or  in  size.  The  order 
of  the  lining  cell  is,  in  so  far,  a  typical  one,  as  the  whole  cavity  is 
filled  with  cells  of  which  only  the  outer  ones  are  c}'lindrical  and 
arranged  in  regular  order,  while  the  rest  show  very  irregular  re- 
lations, both  in  form  and  position.  The  cylindrical  cell  carcinoma 
is  most  frequently  found  in  the  pyloric  region,  its  favorite  place 
being  close  to  the  valve,  and  generally  sharply  limited  toward  the 
duodenum.  It  is  probable  that  the  neoplasm  originates  here  from 
the  pyloric  glands,  while  at  other  locations  of  the  stomach  the  sur- 
face epithelium  and  the  cylindrical  cells  of  the  gland  vestibules  form 
the  bases  of  origin.  The  papillary  forms  of  these  cancers  particu- 
larly have  a  tendency  to  grow  toward  the  surface,  for  they  may  last 
a  long  time;  /.  c,  the  cancer  mass  may  assume  a  considerable  size 
before  the  infiltration  will  invade  the  outer  layers  of  the  stomach 
wall.  The  development  of  secondary  carcinomata  may  also  take 
a  long  time,  so  that  with  very  large  malignant  neoplasms  perhaps 
only  one  or  a  few  lymph  glands  will  be  found  secondarily  in- 
volved. Finally,  ulcerations  of  the  surface  may  prolong  develop- 
ment; or,  if  a  loss  of  substance  does  occur,  it  maybe  compensated 
for  by  proliferation  of  the  tumor  tissue ;  eventually,  however,  with 
the  co-operation  of  necrosis,  a  larger  destruction  occurs.  The  ul- 
ceration is  usually  surrounded  by  a  projecting  fungus-like  wall. 

Occasionally  the  ensuing  necrosis — which  presumably  arises 
from  disturbances  in  the  circulation — may  become  so  extensive 
that  the  entire  tumor,  with  the  exception  of  very  few  remnants, 
may  be  sloughed  off,  leaving  behind  an  ulcerating  base.  The  break- 
down and  destruction  of  the  tumor  mass  frequently  progresses  in 
a  gangrenous  manner,  and  then  we  may  find  not  only  formations 
of  cavities  within  the  tumor,  but  the  entire  stomach  walls  may  also 
be  perforated,  while  large  cancerous  proliferations  are  still  left 
close  to  the  perforation. 

The  second  main  type,  the  soft  glandular,  or  medullary,  car- 
cinoma, likewise  forms  knotty  projections  on  the  inner  surface  of 
the  stomach,  but  it  is  very  rare  that  these  are  observed  intact ;  on 
the  contrary,  this  type  of  cancer  usually  appears  at  the  necropsy 
as  a  cancerous  ulceration.  Its  form  is  quite  characteristic.  It  pre- 
sents a  navel-like,  deepened  center   and   an  external  surrounding 


496 


MALIGNANT    TUMORS    OF    THE    STOMACH. 


wall  which  is  formed  by  the  mass  of  the  tumor;  it  is  either  broad 
or  narrow,  high  or  low  ;  at  times  it  exhibits  a  uniform  appear- 
ance ;  again,  it  is  irregularly  ragged  in  outline.  In  the  bowl-shaped 
central    depression   the    tumor   mass    is   found   breaking  down  in 


^l{f^>» 


% 


^^--=-,,^-  ..•    -.'    ^  ^.,  ^.V^  -'^^^     ^-5^"'  ••  ':s*"if«^'^ 


':."**.*-.it 


Fig.  37. — A  Portion  of  an  Akea  in  the  Submucosa,  Largely  Composed  of  Groups  of 

Cancer  Cells. 

Objective,  one-sixth.     Eyepiece,  one  inch.     Stained  with  hematoxylin  and  orange  G. 
X  about  320  diameters. 

The  fibrous  tissue  of  the  mucosa  is  infiltrated  with  many  small  round  cells,  which  in  some  places  are 
very  numerous,  A,  A  The  most  prominent  change  appears  in  the  numerous  clumps  of  cancer  cells,  most 
all  of  which  lie  in  open  spaces  in  the  tissue,  B.  These  clumps  are  like  those  seen  in  other  coats  of  the 
stomach,  but  the  attempt  at  glandular  formation  is  more  marked  here  than  in  any  other  locality,  C,  C.  In 
the  upper  part  of  the  cut  is  seen  the  lower  portion  of  the  muscularis  mucosae,  D,  D,  infiltrated  with 
many  small  round  cells,  and  containing  a  few  of  the  masses  of  cancer  cells. 


fragments,  or,  occasionally,  this  depression  may  be  found  smooth, 
since  the  more  resistant  muscularis  may  have  been  exposed  and  is, 
presumably,  destroyed  much  more  slowly  than  the  other  layers  by 


MEDULLARY    CARCINOMA. 


497 


the  action  of  the  gastric  juice.  In  this  tumor  also  the  destruction 
may  go  on  to  complete  perforation  of  the  gastric  wall.  The  masses 
of  the  tumor  which  surround  the  ulceration  denote  more  or  less  ex- 
tensive retrogressive  metamorphoses,  accompanied  by  hemorrhages, 
and,  not  rarely,  an  ichorous  deterioration  of  the  tumor  mass.  On 
microscopical   examination  of  these  masses,  it  is  noticed  that  the 


be       q. 


Fig.    3S. — Section  of   Tissue   Near  the  Base    of  a   Carcinomatous  Ulcer,   Showing   Micro- 
organisms. 

Objective,  one-twelfth.     Eyepiece,  one  inch.     Stained  with  methyl-violet,  anilin-oil   solution  by  Gram's 

method.     X  1060  diameters. 

a,  a,  a.  The  Oppler-Boas  bacillus,  singly  and  in  chains.  The  peculiar  base-ball  bat  shape  is  shown  in 
some  cases,  while  in  others  it  is  seen  that  one  end  of  the  rod  is  narrow  and  the  other  broad,  the  change 
in  size  being  sudden.     Some  of  the  rods  stain  solidly,  while  in  others  there  are  clear  spaces. 

b,  b,  b.  A  micrococcus  which  occurs  .'-ingly  and  in  clumps,  but  never  in  chains.  These,  as  well  as  the 
Oppler-Boas  bacillus  and  the  next  organism  to  be  described,  were  found  both  in  the  necrotic  tissue  over 
the  base  of  the  ulcer  and  in  the  healthy  tissue  below  the  same. 

c,  c,  c.  A  peculiar  yeast-like  organism,  that  is  probably  some  protozoan.  It  is  much  smaller  than  a 
yeast  cell.  Budding  forms  are  seen,  and  the  granular  protoplasm  in  some,  and  the  few  large  deeply 
staining  dots  in  others,  are  well  represented. 


cancer  cells  are,  as  a  rule,  quite  small  and  irregularly  shaped,  simi- 
lar to  oxyntic  cells,  but  that  their  numbers  far  exceed  the  stroma, 
which  in  many  places  consists  chiefly  of  very  thin,  delicate  parti- 
tions. Larger  supporting  partitions  of  the  stroma  exist,  of  course, 
in  addition  to  these,  and  in  this  latter  type  "  small-celled  infiltra- 
tion "  is  regularly  present.      Microscopical  examination  evinces  the 


498  MALIGNANT    TUMORS    OF    THE    STOMACH. 

fact  that  the  soft  glandular  cancer  rapidly  invades  the  exterior 
gastric  layers,  for  small  nodules  (tumor  knots)  appear  at  the  serosa  at 
an  early  stage,  which  nodules  distinctly  show,  and  correspond  to, 
the  course  of  the  lymphatic  vessels.  These  nodules  have  arisen 
by  a  direct  advance  of  the  cancer  into  and  through  the  muscular 
layer,  in  which,  microscopically,  a  distinct  thickening  is  observed, 
this  thickening  being  dependent  upon  proliferation  of  the 
mnscular  substance  itself,  as  well  as  upon  .a  broadening  of  the 
intermuscular  connective  septa  (Fig.  36).  Examining  micro- 
scopically a  section  through  the  muscularis,  it  at  once  becomes 
evident  that  the  cancer  masses,  in  their  invasions  between  the  mus- 
cular fibers,  follow  the  septa  which  conduct  the  lymphatic  vessels. 
In  older  cases,  small  foci  are  found  in  the  muscle-bundles  them- 
selves, where  they  have  forced  apart  the  muscle  cells  to  assume  the 
shape  of  spindle-like  spaces.  As  the  growth  of  the  carcinoma  is 
much  more  restricted  in  the  denser  and  closer  netted  muscularis 
than  in  the  subserosa,  the  cancer  masses  outside  of  the  muscular 
layer  are  generally  considerably  more  voluminous  than  those 
within  it.  The  (soft)  medullary  carcinoma  may  extend  toward  the 
surface  as  well  as  toward  the  interior,  and  it  will  then  be  seen  that 
it  habitually  follows  preformed  passages — namely,  the  lymphatic 
vessels.  In  very  rare  cases  this  neoplasm  may  extend  over  the 
whole  stomach,  except,  possibly,  the  fundus ;  and  in  such  a 
case  Orth  has  found  that  the  entire  lymphatic  network  of  the 
mucosa,  as  well  as  of  the  submucosa,  was  filled  with  cancerous 
masses.  The  greater  tendency  of  the  medullary  carcinoma  for 
local  dissemination  corresponds  to  its  relations  toward  the  general 
organism.  With  this  neoplasm  particularly,  one  finds  extensive 
lymphatic  gland  carcinomata,  not  only  in  the  epigastric,  celiac, 
portal,  and  retroperitoneal,  but  also  very  frequently  in  the  left 
supraclavicular  lymph-glands ;  one  may  find  metastases  in  the 
lymph-  as  well  as  in  the  blood-channels,  and,  besides,  a  dissemina- 
tion of  cancerous  nodules  in  the  abdominal  cavity. 

Concerning  the  seat  of  medullary  cancers,  it  may  be  said  that 
they  are  not  limited  to  any  particular  part  of  the  stomach,  for  they 
maybe  found  at  the  cardia,  the  anterior  and  posterior  walls,  and  the 
lesser  curvature  as  well  as  in  the  pyloric  region,  for  which  they 
have  an  unmistakable  affinity.  Frequently,  cancers  of  the  cardia 
extend  to  the  esophagus,  while  the  duodenum  remains  intact. 

The  scirrhus  (meaning  hard  glandular)  is  distinguished  from  the 


THE    GASTRIC    SCIRRHUS.  499 

two  preceding  types  of  carcinoma  mainly  by  its  hardness.  It  pro- 
duces no  large  tumor  nodules,  but  rather  simple  thickenings  of  the 
entire  wall.  The  surface  of  the  mucosa  shows,  as  a  rule,  a  flat  ulcer- 
ation, which  has  either  a  smooth  or  an  actually  cicatricial  basis,  or 
else  a  papillomatous,  irregular,  and  corroded  appearance.  The  edges 
of  the  ulcerations  are  generally  entirely  flat,  without  a  trace  of  the 
wall-like  elevation,  and  for  that  reason  the  transition  into  the  sur- 
rounding mucosa  is  very  gradual.  On  cutting  through  a  scirrhous 
gastric  wall  considerable  resistance  is  met  with,  so  that  the 
tissue  actually  grates  on  cutting.  Microscopical  section  reveals  a 
thickening  of  all  layers,  particularly  of  the  muscularis,  by  a  gra}'- 
ish-white,  striated,  cicatricial  connective  tissue.  Typical  cancer- 
ous proliferation  is  not  apparent  on  the  mucosa  nor  in  the  remain- 
ing layers  of  the  gastric  wall,  so  that  it  may  be  doubtful  whether 
one  is  dealing  with  a  cancer  or  with  a  simple  chrt)nic  ulcer.  To 
decide  this  question  one  must  observe  the  relation  of  other  parts, 
and,  particularly,  search  for  secondary  cancer  formation. 

As  a  matter  of  fact,  one  occasionally  sees  small,  flat  tumor 
nodules  on  the  serosa  directly  over  the  neoplasm  ;  but  as  exten- 
sive adhesions  of  the  pylorus  with  neighboring  organs  (liver,  intes- 
tine, omentum)  are  invariably  present  with  this  form  of  cancer, 
implicating  the  peritoneum,  such  nodules  are  difficult  to  recognize, 
even  if  they  are  present.  A  more  reliable  sign  is  the  condition  of 
the  lymphatic  glands,  which  usually  show  cancer  formation;  and, 
besides  this,  the  liver  and  other  organs,  which  are  otherwise  rarely 
invaded  (for  instance,  the  spinal  column),  may  be  found  to  contain 
it.  Such  cases  easily  give  rise  to  deception,  because  these  second- 
ary tumors  may  show  a  medullary  structure  and  attain  con- 
siderable size,  in  which  case  the  seemingly  unimportant  scirrhous 
ulceration  in  the  stomach  may  be  overlooked.  The  surest  indica- 
tion of  the  character  of  these  changes  is  obtained  from  microscop- 
ical examination,  though  in  a  section-preparation  hardly  anything 
else  but  fibrous  connective  tissue  is  seen,  particularly  in  the  very 
much  thickened  muscularis,  which  is  permeated  with  broad,  gray- 
ish-white stripes.  But  when  a  larger  number  of  preparations  are 
carefully  examined  the  histological  peculiarities  of  carcinoma, 
the  connective-tissue  stroma,  and  carcinoma  bodies  are  discovered. 

The  last-named  are  diminutive  and  consist  of  small-celled  rows. 
The  stroma  is  massive,  and  composed  of  tough,  rigidly  fibered  con- 
nective tissue.     The  longitudinal  direction  of  the  small-cell  rows  is 


500  MALIGNANT    TUMORS    OF    THE    STOMACH. 

parallel  to  the  course  of  the  fibers  of  the  stroma.  It  is  noteworthy 
that  the  secondary  cancer  nodules  of  scirrhus  are  richer  in  cells, 
and  therefore  more  closely  resemble  the  medullary  carcinoma  ; 
and  also  that,  alongside  entirely  fibrous  places  in  the  gastric  wall, 
here  and  there  at  the  edges  of  the  ulcerations,  places  can  be  found 
where  the  cancer  cells  are  not  yet  so  scarce  in  proportion  to  the 
stroma,  and  where  the  latter  does  not  as  yet  possess  the  character- 
istic callous  consistency.  It  may,  from  this,  be  concluded  that  the 
scirrhus  is,  in  fact,  an  atrophic  cancer  [cancer  atropliicans) ;  /.  e., 
that  the  callous  formation  represents  nothing  more  than  a  later 
stage,  or  result,  of  the  initial  cancerous  process.  The  question  has 
arisen,  whether  complete  healing  may  not  be  produced  by  a  total 
callous  metamorphosis  of  the  neoplasm ;  but,  up  to  the  present 
time,  no  convincing  observations  confirmatory  of  this  question 
have  been  made.  It  is  reasonable  to  assume  that  a  very  localized 
callous  cicatricial  healing  may  be  brought  about  in  certain  places, 
while  in  other  portions  (the  very  youngest  parts  of  the  neoplasm) 
very  slow  but  gradual  cancerous  progress  is  made.  The  callous 
stroma  of  the  scirrhus  has  a  tendency  to  contract  such  formations. 

This  fact  is  of  great  significance,  when  the  microscopical  rela- 
tion of  the  scirrhus  is  considered,  for  it  explains  the  stenosis  which 
it  causes  at  the  pylorus, — its  almost  exclusive  locality.  This 
constriction  is  further  increased  by  the  very  much  thickened  and 
callous-like  alteration  of  the  gastric  wall,  which  becomes  unresis- 
tant  and  inelastic,  resembling  a  hard,  rigid  ring  or  stiff  tube. 
It  is  self-evident  that  a  pylorus  changed  in  this  manner  is  no  longer 
capable  of  closing  oft''  the  stomach  toward  the  duodenum  (incon- 
tinence of  the  pylorus).  The  extent  of  the  scirrhus  from  the 
pylorus  toward  the  cardia  may  be  variable,  rare  cases  occurring  in 
which  the  entire  gastric  wall  is  in  a  state  of  scirrhous  degeneration. 
The  entire  organ  is  then,  as  a  rule,  considerably  contracted,  and  at 
the  same  time  the  walls  are  very  much  thickened.  On  the  inner 
surface  little  mucous  membrane  remains  in  these  cases.  We  have 
seen  elsewhere  that  a  similar  condition  may  be  brought  about  by 
chronic  inflammation  (cirrhosis  of  the  stomach).  The  differential 
diagnosis  is  very  difficult  to  establish  from  the  local  conditions, 
but  the  majority  of  stomach  contractions  are  to  be  attributed  to 
scirrhus  (Orth,  loc.  cit.). 

The  colloid  carcinoma  in  typical  cases  has  a  very  characteristic 
appearance.     It  does  not  produce  circumscribed  tumor  masses  so 


THE    COLLOID    CARCINOMA    OF    THE    STOMACH.  50I 

much  as  diffuse  thickenings  of  the  entire  wall  similar  to  scirrhus. 
In  this  growth  the  stroma  is  not  a  bright  fibrillar  tissue,  but  a  gela- 
tinous, translucent,  colorless  or  light-brown  material.  These 
masses  are  recognizable  on  the  inner  surface,  which,  as  a  rule, 
presents  an  extended  flat  ulceration.  Where  the  tumor  tissue  lies 
exposed  there  appears  a  distinct,  alveolar,  grayish  framework, 
which  incloses  the  colloid  granules,  in  dimension  the  size  of  a  pin- 
head  or  a  millet  seed.  The  whole  mass  has  a  slimy,  mucoid 
feeling,  but  it  is  not  nearly  as  soft  as  is  genuine  mucus.  Micro- 
scopically a  similar  picture  obtains  ;  for  here,  also,  the  connective- 
tissue  alveolar  framework,  containing  a  transparent  mucocolloid 
mass  in  its  meshes,  is  prominent.  This  mass  may  be  entirely 
devoid  of  cellular  elements,  but  generally  a  number  of  cells  and 
cell  fragments  are  detected,  in  which  it  can  be  distinctly  recog- 
nized that  these  cells  themselves  furnish  the  colloid  material  of  the 
alveoli,  for  one  frequently  sees  many  cells  in  a  swollen  state,  either 
with  hyaline  granules  or  in  a  condition  of  disintegration.  In  other 
places  cells  may  be  found  in  better  preservation,  while  the  colloid 
matter  is  not  so  pronounced,  so  that,  in  this  form  of  carcinoma, 
just  as  in  scirrhus,  there  are  transitions  to  the  medullary  type. 
Here,  likewise,  the  youngest  portions  of  the  growth  are  those 
most  rich  in  cellularel  ements,and  production  of  colloid  material  is 
a  phenomenon  which  occurs  in  the  course  of  further  development 
of  the  tumor. 

"  Colloid  tissue  "  several  centimeters  thick  maybe  found  through- 
out the  entire  gastric  wall,  and  here  again  the  lymph-vessels  offer 
the  channels  in  which  the  cancerous  masses  take  their  course,  and 
in  which  they  ramify  both  interiorly  and  superficially.  Occasionally, 
larger  colloid  tumor  nodules  may  appear  on  the  serosa;  and,  in 
fact,  the  colloid  carcinoma  not  rarely  invades  the  peritoneum  and 
produces  an  extensive  carcinosis — as  a  result  of  which  the  omen- 
tum is  transformed  into  a  short,  thick,  and  board-like  band.  Af- 
fections of  the  lymphatic  glands,  liver,  lungs,  and  other  organs,  are 
by  no  means  absent.  The  colloid  carcinomata  also  have  their 
favorite  location  in  the  pyloric  region,  whence  they  may  extend  to 
the  duodenum,  and  also  to  the  liver,  by  direct  continuity.  The 
extension  to  the  liver  generally  occurs  after  the  formation  of  a 
previous  adhesion.  A  transition  to  the  esophagus  from  the  cardia 
has  likewise  been  observed.  Although  the  colloid  carcinoma  pro- 
duces no  large  prominent  tumors  it  may  extend  far  over  the  gastric 


502  MALIGNANT    TUMORS    OF   THE    STOMACH. 

surface,  and  frequently  takes  in  the  entire  wall,  reducing  the  size  of 
the  stomach  somewhat  but  not  to  such  a  degree  as  scirrhus.  The 
wall  is  hard  and  immovable,  the  inner  surface  ulcerated,  the  outer 
coarsely  granular  from  small  and  large  cancerous  nodules  of  the 
peritoneal  covering. 

Although  the  ulcerations  of  the  colloid  carcinoma  may  have  con- 
siderable superficial  extent,  still  a  perforation  rarely  results,  although 
the  ulcerations  may,  at  places,  reach  even  to  the  peritoneum.  The 
colloid  tissue  is  not  subject  to  rapid  disintegration,  hence  new 
tumor  masses  may  be  formed  in  front  of  the  basis  of  ulceration. 

Structural  Effects  of  Malignant  Gastric  Neoplasms. — The 
development  of  gastric  carcinoma  is  accompanied  by  adhesions  of 
the  serosa  with  the  pancreas,  liver,  the  transverse  colon,  the  anterior 
abdominal  wall,  and  the  omentum;  and,  at  the  same  time, there  occurs 
a  callous  hyperplasia  of  all  connective  tissue  in  the  immediate  neigh- 
borhood. The  result  is  that  the  stomach,  particularly  the  part 
most  frequently  affected  (namely,  the  pylorus),  becomes  fixed, 
while  in  other  rare  cases  such  adhesions  may  not  be  formed,  and 
the  stomach  is  dislocated  downward  by  the  tumor  masses,  in  which 
case  the  pylorus  may  extend  as  far  as  the  symphysis  pubes.  Fre- 
quently the  cancerous  stomach  exhibits  changes  of  size  and  form. 
We  may  have  diminutions  in  size  accompanying  the  total  degen- 
erations of  stenosing  cardiac  carcinomata,  or,  what  is  more  common, 
dilatation  accompanied  by  marked  muscular  hypertrophy.  The 
dilatations  originate  from  the  obstruction  of  the  passage  through 
the  pylorus,  a  pyloric  stenosis  existing.  This  may  be  caused  by  a 
variety  of  circumstances.  Among  the  causes  so  operating  may  be 
mentioned,  in  the  first  place,  a  large  tumor  mass  located  in  the 
pyloric  orifice,  acting  like  a  cork  or  ball-valve  ;  secondly,  the  rig- 
idity which  the  walls  undergo  in  scirrhus  and  in  colloid  carcinoma  ; 
finally,  the  effective  contractions  of  the  scirrhus,  whereby  a  consid- 
erable resistance  is  offered  against  the  advance  of  the  gastric  con- 
tents. These  disturbances  may  be  increased  by  a  large  variety  of 
inflections  and  dislocations  resulting  from  adhesions,  as  well  as  by 
the  weight  of  the  accumulating  gastric  contents.  Incontinence  of 
the  pylorus  may  occur  contemporaneously  with  stenosis,  but  it 
may  also  exist  in  a  very  severe  degree  without  stenosis  where  the 
cancerous  ulceration  has  destroyed  more  or  less  of  the  pyloric  ring. 
These  changes  at  the  pylorus  are  important  because  they  are  very 
frequent,  for,  as  is  evident  from  what  we  have  said   concerning  the 


STRUCTURAL  EFFECTS  OF  GASTRIC  CANCERS.         5O3 

various  types  of  carcinoma,  the  pyloric  antrum  is  the  most  frequent 
seat  of  cancer  formation.  According  to  the  statistics  of  WiUiam 
H.  Welch  ("  A  System  of  Practical  Medicine  by  American  Authors," 
edited  by  William  Pepper,  vol.  11,  page  561),  the  frequency  of 
carcinomata  occurring  at  the  pyloric  region  is  60.8  per  cent. ;  at  the 
lesser  curvature,  11.4  per  cent.  ;  at  the  cardia,  8  per  cent. ;  at  the 
posterior  wall,  5.2  per  cent.;  the  whole,  or  the  greater  part  of  the 
stomach,  4.7  per  cent.  According  to  Orth,  60  per  cent,  of  all  gas- 
tric cancers  invade  the  pylorus ;  20  per  cent.,  the  lesser  curvature ; 
10  per  cent,  the  cardia  ;  and  the  rest,  the  remaining  parts  of  the 
stomach.  As  gastric  carcinoma  makes  up  35  to  40  per  cent,  of  all 
carcinomata,  the  great  importance  of  pyloric  cancer  can  be  appre- 
ciated. In  the  mid-regions  of  the  stomach  the  cancers  are  limited 
to  a  portion  of  the  circumference,  but  in  the  vicinity  of  the  two 
openings  they  frequently  occupy  the  entire  circumference  in  a  ring- 
er girdle-shaped  manner. 

The  growth  of  carcinomata  occurs  partly  through  simple  periph- 
eral extension,  partly  through  daughter-nodules  which  develop 
at  some  distance  from  the  main  tumor,  but  sooner  or  later  coal- 
esce with  it.  These  nodules  evidently  lie  underneath  the  mucosa, 
which  may  be  movable  over  them  ;  hence,  it  may  be  assumed  that 
they  have  arisen  through  infection  by  way  of  the  lymph-channels. 
The  frequent  occupation  of  lymphatic  vessels  by  cancer  masses 
in  the  neighborhood  of  larger  nodules  argues  in  favor  of  this  view. 
Concerning  the  secondary  infection  of  lymph-glands,  it  may  be 
stated  that,  with  gastric  carcinomata,  it  often  happens  that  glands 
are  diseased  which  do  not  receive  their  lymph  from  the  direction 
of  the  stomach  ;  such  glands  are  the  retroperitoneal.  It  is  pos- 
sible that  this  is  caused  by  the  cancerous  impermeability  of  glands 
located  higher  up,  which  compels  a  return  of  the  lymph-current. 
Following  the  current  of  the  lymph,  it  has  been  found,  by  Orth 
and  others,  that  the  thoracic  duct  may  be  infected.  Possibly,  the 
infection  of  the  left  supraclavicular  lymph-glands  occurs  in  con- 
nection with  the  transportation  of  cancer  cells  through  the  lymph 
of  the  thoracic  duct.  The  lymph-vessels  of  the  diaphragm  may  be 
entirely  filled  with  cancerous  masses,  and  may  disseminate  the  ele- 
ments of  the  disease  to  the  pleural  cavity,  bronchial  glands,  and  lungs. 
In  25  per  cent,  of  all  gastric  cancers  secondary  nodules  are  contained 
in  the  liver,  and  are  transported  there  by  direct  extension  after 
"  adhesive    invasion "    with    the    lymph-current    from    the    porta 


504  MALIGNANT    TUMORS    OF   THE    STOMACH. 

hepatica  and  transportation  by  the  blood-stream,  the  latter  mode 
being  by   far    the    more    plausible.     The    metastases    may    occur 
through  minute  particles  which  are  not  retained  emboli,  whereas 
in  other  instances  emboli  can  be  demonstrated  in  the  larger  vessels, 
certifying  that  such  emboli  should   originate   from   the  stomach, 
because  the  gastric  veins  are  roots  of  the  portal  vein,  and  cancer- 
ous   invasion    of    the    veins    of   the    stomach    is    conceded.     The 
spreading  of  gastric  cancer  to  the  esophagus,  duodenum,  spleen, 
pancreas,  and  intestines  occurs  by  direct  extension  along  the  paths 
that  are  either  normally  present   or  newly  formed   pathologically. 
Participation   of  the  peritoneum   has   its  foundation  in  the  direct 
extension  of  the  carcinoma  into  the  gastric  serosa  ;  when,  however, 
the  peritoneum  is  once  invaded,  the  rest  of  it  is  not  affected  by  con- 
tinued  simple   extension   of  the  growth,  although  this  may  occur 
with  colloid  carcinomata,  but  by  dissemination,  which  means  the 
falling  of  tiny  particles  into  the  peritoneal  cavity  (carcinoma  seed,  as 
it  were)  and   their  attachment  in  suitable  places    (at  first  in  the 
deepest  portions  of  the  peritoneum,  in  the  rectovesical   and   recto- 
uterine   pouch).     It  is  evident  that  gravity   is  an  element  in  the 
spreading    of  peritoneal  carcinoma.     The    ulcerations    of   gastric 
cancers    depend    partly    upon    ichorous    degeneration    and    sup- 
puration  and    partly   upon  the   digestive  influence  of  the  gastric 
juice,  which  occasionally  causes  perforation  of  the  stomach.     The 
vessels  of  the  stomach  and  of  the  spleen  may  be  affected  by  an 
inflammatory  gangrenous  ulceration,  which  may  lead  to  dangerous 
hemorrhages,  but  these  cases  are  infrequent.     Cancerous  ulcera- 
tions are  very  similar  to  the  simple  peptic  ulcer,  from  which  they 
may  be   distinguished    only  by  the   presence  of  the  tumor  wall, 
which,  if  absent,  enhances  the  difficulty  of  distinction  between  the 
two.     If,  indeed,  cancer  masses  are  found  in  the  surroundings  of 
such  an  ulceration,  the  question  may  be  asked.  Has  the  ulceration 
arisen  from    a    carcinoma,    or    has    a    simple    gastric    ulcer    been 
secondarily  affected  by  cancer  transformation  ?     Here  the  clinical 
history,  as  well  as  the  examination  and  analysis  of  gastric  contents, 
may  give  the   desired  information.     Rosenheim   has  shown  that 
normal  or  supernormal  hydrochloric  acid  secretion  persists  in  the 
carcinoma  which  has   secondarily  developed  from   an   ulcer;  but 
when  the  carcinoma  is  the  primary  growth,  the  hydrochloric  acid 
is  permanently  absent  at  an  early  stage  in  the  disease. 

Anatomically,  it  may  be  stated  that  when  the   ulceration  has  a 


ORIGIN    OF    GASTRIC    CANCER.  505 

regular  bowl-shaped  appearance,  and  is  on  every  side  surrounded 
by  tumor  masses,  even  where  no  cancer  masses  can  be  found  in  its 
base,  the  carcinomatous  tumor  was  undoubtedly  the  primary,  the 
ulceration  the  secondary,  object;  and,  reversely,  when  a  simple 
ulcer,  accompanied  by  all  typical  peculiarities,  presents  a  thick- 
ening only  at  one  side,  the  latter  tumor  mass  must  be  regarded  as 
secondary  and  the  ulcer  as  primary.  The  remaining  gastric 
mucous  membrane  sometimes  shows  insignificant  alterations,  which 
agrees  with  clinical  observations  as  to  gastric  cancers  remaining 
latent.  In  other  cases  a  pronounced  chronic  inflammation  is  pres- 
ent, particularly  in  the  immediate  vicinity  of  the  tumor  masses  or 
ulcerations.  A  hypertrophy  of  the  musculature  is  frequently 
apparent,  which  partly  depends  upon  alterations  in  the  mucosa 
and  partly  upon  a  pyloric  stenosis,  the  latter  being  responsible  for 
the  condition  of  the  gastric  contents,  because  it  provokes  dilata- 
tion and  its  consequences.  The  loss  of  secretion  and  the 
admixture  of  blood  with  the  gastric  contents  is  directly  traceable 
to  the  cancerous  infiltration.  The  hemorrhages  may  arise  by 
ulcerative  disintegration,  as  well  as  from  rupture  of  the  small  ves- 
sels in  the  villous  cancer  proliferations. 

What  is  the  source. or  basis  of  the  primary  development  of  can- 
cer formation  ?  According  to  prevalent  views,  all  gastric  carci- 
nomata  do  not  originate  from  the  connective  tissue  of  the  sub- 
mucosa,  as  was  formerly  believed,  but  from  the  mucosa,  and  par- 
ticularly from  the  glandular,  or  surface,  epithelium  of  the  same, 
the  cells  of  these  carcinomata  having  great  similarity  to  the  various 
cells  of  the  mucosa.  All  gastric  carcinomata  are  therefore  epithe- 
lial tumors.  We  owe  to  Waldeyer  the  first  exact  investigations 
concerning  the  beginning  of  cancer  formation,  which  have  been 
confirmed  later  by  other  researches.  According  to  him,  the  pro- 
cess begins  with  an  enlargement  and  hypertrophy  of  a  group  of 
ten  or  twelve  glands,  which,  breaking  through  the  muscularis 
mucosa,  enter  the  submucosa.  The  cells  of  these  gland-ducts  react 
differently  to  staining  reagents,  being  colored  much  deeper  by 
them,  and  filling  the  lumen  of  the  gland  in  an  irregular  manner. 
A  further  step  is  that  the  connective  tissue  of  the  mucosa,  and  par- 
ticularly of  the  submucosa,  undergoing  a  transformation  into  gran- 
ulation-tissue, advances  and  is  pushed  up  against  the  aggregations 
of  epithelial  cells,  which  are  thus  forced  apart  and  inclosed  in 
groups    by    the    connective    tissue,     giving    rise    to    the    cancer 


506  MALIGNANT  TUMORS  OF  THE  STOMACH. 

alveoli  and  cancer  bodies  (cancer  cells).  Accepting  this  as  a 
general  rule,  the  question  arises,  What  causes  this  gland-group 
and  the  adjoining  connective  tissue  to  enter  upon  this  abnormal 
growth  ?  Cohnheim  says  that  abnormal  conditions  of  primitive 
germinal  tissue  are  present  here,  a  remnant  of  unused  primitive 
cells  from  which  the  proliferation  starts.  This  is  a  hypothesis 
which  can  admit  of  no  proof,  since  after  the  proliferation  has 
occurred  it  is  impossible  to  obtain  any  knowledge  of  the  condition 
of  the  locality  that  existed  there  prior  to  the  proliferation.  But 
even  admitting  Cohnheim's  theory,  we  must  ask,  Why  do  these 
embryonic  cells  suddenly  begin  to  grow  after  many  years  ?  There 
must  evidently  be  some  other  incentives  to  growth. 

There  is  undoubtedly  some  disposition  toward  the  development 
of  gastric  cancers  with  advancing  age.  What  the  nature  of  this 
predisposition  is  we  do  not  know.  There  seems  to  be  no  predis- 
position of  sex,  for  both  sexes  are  attacked  with  equal  frequency. 
The  pronounced  tendency  which  the  structures  of  the  pylorus 
exhibit  toward  cancerous  infection  attracts  attention  to  the 
mechanical  relations  there  existing.  Hauser  has  made  some  in- 
teresting observations  on  the  development  of  cancers  from  simple 
peptic  ulcers.  He  has  shown  that  the  gastric  secretory  glands  at 
the  edges  of  healing  ulcers  undergo  a  proliferation  which  may  be 
augmented  to  a  cancerous  neoplasm,  and  he  seeks  the  explanation 
for  this  process  in  an  increased  supply  of  nutritive  material  to  the 
glands,  and  in  a  reduction  of  the  resistance  of  the  adjoining  tissues 
in  consequence  of  an  ulcerative  and  cicatricial  process. 

As  frequent  as  primary  carcinomata  are,  just  so  rare  are  the 
secondary.  Secondary  cancers  may  arise  in  the  stomach  by  direct 
extension  from  the  immediate  surroundings.  In  this  manner  a 
cancer  might  extend  to  the  gastric  walls  from  the  pancreas,  liver, 
and  lymphatic  glands.  Clinically,  the  most  important  of  the  primary 
carcinomata  is  the  esophageal,  which,  when  it  is  located  at  the  cardia, 
may  invade  the  stomach.  Reversely,  the  extension  of  gastric  cancer 
into  the  esophagus  is  really  more  frequent.  There  is  another 
kind  of  extension  of  esophageal,  lingual,  and  facial  carcinomata  to  the 
stomach,  which  is  not  transmitted  by  the  lymph-  or  blood-channels 
but  by  a  direct  implantation  of  cancer  cells  upon  the  mucosa. 
Klebs  was  the  first  to  report  three  of  such  cases,  and  Beck  has  in- 
vestigated a  case,  concerning  which  he  assumes,  on  the  strength  of 
his  microscopical  preparations,  that  the  loosened  parts  of  the  esoph- 


THEORY    OF    INFECTIOUS    ORIGIN    OF    CANCER.  507 

ageal  cancer  had  fastened  themselves  in  the  gastric  glands.  The 
new  nodules  which  were  thus  formed  were  flattened  epithelium 
carcinomata,  composed  of  the  typical  pavement-epithelium  of  the 
esophagus.  This  raises  the  interesting  question  whether  the  new 
tumors  arise  solely  and  exclusively  from  the  implanted  tumor  cells, 
or  whether  these  cells  produce  a  kind  of  infection  of  the  local  cells 
upon  which  they  fall,  so  that  the  latter  are  converted  into  pavement- 
epithelium  cancer  cells.  Klebs  assumes  the  latter  view,  but  Beck 
leaves  the  question  undecided.  In  the  place  occupied  by  the  tumor 
that  he  investigated,  no  gastric  cells  were  observable,  and  also  no 
transition  forms  to  pavement  cells.  The  secondary  cancers  of  the 
peritoneum,  already  described,  arise  in  a  similar  manner,  namely,  by 
the  falling  of  cancer  particles  into  the  peritoneal  cavity.  Reversely, 
it  has  been  observed  that  an  implantation  carcinoma  may  arise  upon 
the  gastric  serosa  from  a  deeper  portion  of  the  abdominal  cavity. 
Orth  describes  a  case  in  which  the  inner  mucous  membrane  of  the 
pylorus  showed  a  typical  cylindrical  cell  carcinoma,  while  the  serosa 
of  the  same  viscus  revealed  a  pronounced  colloid  nodule  as  large  as 
a  walnut,  which  could  not  have  arisen  in  any  other  way  except  by 
implantation  from  a  colloid  carcinoma  of  the  cecum.  Another 
mode  of  secondary  cancer  formation  is  that  of  metastasis  by  way 
of  the  blood-vessels,  these  secondary  neoplasms  corresponding  to 
the  primary  tumors  in  structure,  and  are  recognizable,  according  to 
Grawitz,  as  secondary  by  their  circumscribed  character.  These 
secondary  forms  are  rare. 

The  theory  of  infection  for  the  origin  of  gastric  cancers  would 
not  explain  the  great  variety  of  the  histogenesis  of  the  carcinoma. 
In  accepting  the  existence  of  a  "  cancer-producing  microbe,"  one 
would  have  to  assume  that  this  organism  could  produce  a  transfor- 
mation of  connective  tissue  into  epithelium,  or  that  it  regularly 
produced  proliferation  only  in  one  kind  of  tissue,  namely,  the 
epithelial.  A  pathogenic  micro-organism  with  these  qualities  is 
unknown  at  the  present  time.  In  the  formation  of  metastases, 
only  the  transported  cancer  cells  keep  on  proliferating  in  the  new' 
organ,  while  the  tissue  of  this  organ  either  does  not  participate  at 
all,  or  only  to  a  small  degree,  in  the  formation  of  the  new  cancer 
nodule.  In  the  transportation  of  tuberculous  tissue,  however,  it 
is  this  tissue  which  breaks  down,  and  the  new  tuberculous  focus 
develops  from  the  invasion  of  the  transported  tubercle  bacilli, 
which  not  only  cause  a  disease  of  the  epithelium,  but  also  of  the 


508  MALIGNANT    TUMORS    OF    THE    STOMACH. 

remaining  tissues  (connective  tissue,  bone,  etc.)  with  which  they 
come  in  contact.  Transplantation  of  carcinoma  into  animals  has 
very  rarely  succeeded,  whereas  inoculations  of  infectious  diseases 
are  generally  successful.  Another  explanation  of  the  development 
of  cancer  has  been  attempted  in  the  so-called  "  irritation  theory," 
which  is  based  upon  the  susceptibility  of  the  two  openings  of  the 
stomach  to  greater  irritation  during  digestion  than  other  parts ; 
these  portions  are  consequently  most  frequently  affected  (6o  to  70 
per  cent,  of  all  cases) ;  but  satisfactory  proof  that  this  irritation 
may  cause  cancer /^r  se  is  wanting.  We  have  elsewhere  stated  the 
percentage  of  cancers  occurring  at  various  decads  of  life :  Ac- 
cording to  the  statistics  of  Welch,  Brinton,  and  Lebert,  three-fourths 
of  all  cancers  occur  from  the  fortieth  to  the  seventieth  year,  and 
from  the  thirtieth  to  the  seventieth  year  95  per  cent,  of  all  gastric 
cancers  manifest  themselves.  So  far  as  we  know,  only  one  case  of 
congenital  cancer  that  was  limited  to  the  stomach  has  been  reported 
(Wilkinson).  There  has  been  one  case  of  congenital  cancer  com- 
bined with  carcinoma  of  other  organs  (Widerhofer).  We  found  in 
the  literature  on  this  subject  a  case  of  gastric  cancer  in  a  child  five 
weeks  old  (CuUingworth).  Three  other  cases  in  children  somewhat 
older  are  reported  by  Scheffer.  (The  subject  of  the  etiology  of 
cancer  is  reviewed  in  an  interesting  article  by  Roswell  Park,  N.  Y. 
Med.  Record,  volume  lii,  No.  i,  July  3,  1897.) 

Heredity. — It  is  generally  accepted  that  the  predisposition  to 
cancer  may  be  inherited.  According  to  Fleischer,  the  life  insur- 
ance companies  in  Germany  have  increased  their  premiums  for 
candidates  in  whose  family  gastric  carcinoma  has  been  observed. 
(Napoleon  I,  his  sister,  and  his  father  died  of  gastric  carcinoma.) 

Geographical  Distribution. — The  geographical  distribution  of 
gastric  cancer  is  very  irregular,  for  while  it  is  very  rare  in  some 
countries, — as  in  Turkey,  Egypt,  and  the  tropics, — it  is  said  to  be 
very  frequent  in  Thiiringen,  in  Suabia,  in  Normandy,  and  in  Swit- 
zerland. The  causes  of  this  unequal  distribution  are  unknown. 
In  Egypt  gastric  cancers  are  unknown  (Griesinger),  but  gastritis 
and  enteritis  are  of  common  occurrence.  This  seems  to  show  that 
a  genetic  relation  between  gastritis,  enteritis,  and  carcinoma  does 
not  exist.  According  to  Eichhorst  and  Haeberlin,  two  per  cent, 
of  all  deaths  in  Switzerland  are  caused  by  gastric  cancer.  From 
mortuary  statistics,  Tanchou  ("  Rech.  sur  le  Traitement  Med.  des 
Tumeurs  du    Sein,"  Paris,  1844)  estimates  the  frequency  of  gastric 


GEOGRAPHICAL    DISTRIBUTION    AND    AGE. 


509 


cancer  as  compared  with  that  of  all  causes  of  death  at  0.6  per  cent. ;  * 
Virchow,  at  1.9  per  cent.;  Wyss,  at  2  per  cent.;  and  D'Espine, 
at  2^  per  cent.  In  8468  autopsies,  chiefly  from  English  hospitals, 
Brinton  found  gastric  cancer  recorded  in  i  per  cent,  of  the  cases. 
Gussenbauer  and  von  Winniwarter  found  gastric  cancer  recorded 
in  i}4  per  cent,  of  the  61,287  autopsies  in  the  Pathological 
Anatomical  Institute  of  the  Vienna  University.  From  an  analysis 
of  11,175  autopsies  in  Prague,  Welch  found  gastric  cancer  in 
3^  per  cent,  of  the  cases. 

Welch  has  collected  and  analyzed,  with  reference  to  this  point, 
the  statistics  of  death  from  all  causes  in  the  city  of  New  York  for 
the  fifteen  years  from  1868  to  1882  inclusive,  and  reported  that 
of  444,564  deaths  during  this  period,  cancer  of  the  stomach  was 
assigned  as  the  cause  in  1548  cases  and  cancer  of  the  liver  in  867 
cases.  Some,  at  least,  of  these  so-called  cancers  of  the  liver  may 
be  reckoned  as  gastric  cancers.  This  would  make  the  ratio  of  gas- 
tric cancer  to  all  causes  of  death  about  0.4  per  cent.,  and  nearly 
I  per  cent.  (0.93  per  cent.)  if  only  the  deaths  from  twenty  years 
of  age  upward  be  taken,  gastric  cancer  hardly  ever  occurring  under 
that  age.  It  is  a  fair  presumption,  also,  that  in  New  York  not 
over  I  in  200  of  the  deaths  occurring,  at  all  ages  and  from  all 
causes,  is  due  to  cancer  of  the  stomach,  and  that  about  i  in  100 
of  the  deaths  from  twenty  years  of  age  upward  is  due  to  this  cause. 

The  following  table  (by  William  H.  Welch,  loc.  cit?)  gives  the  age 
in  2038  cases  of  gastric  cancer,  obtained  from  trustworthy  sources 
and  arranged  according  to  decads  : 


Age,      .    .    . 

10-20 

20-30 

30-40 

40-50 

50-60 

60-70 

70-80 

80-90 

90-100 

Over 
100 

No.  of  Cases, 

2 

55 

271 

499 

620 

428 

140 

20 

2 

I 

Per  cent.,     . 

0.1 

2.7 

133 

24-5 

30-4 

21 

6.85 

I 

0.1 

0.05 

From  this  analysis  we  may  conclude  that  three-fourths  of  all 
gastric  cancers  occur  between  forty  and  seventy  years.  The  ab- 
solutely largest  number  is  found  between  fifty  and  sixty  years,  but, 
taking  into  consideration  the  number  of  those  living,  the  liability 
to  gastric    cancer   is  as   great   between   sixty  and   seventy  years. 

*  Tanchous  statistics  are  based  upon  an  analysis  of  382,851  deaths  in  the  Department 
of  the  Seine  (see  Welch,  loc.  cit.,  p.  532). 


UO 


MALIGNANT   TUMORS    OF   THE   STOMACH. 


Nevertheless,  the  number  of  cases  between  thirty  and  forty  years 
is  considerable,  and  the  occurrence  of  gastric  cancer  even  between 
twenty  and  thirty  is  not  so  exceptional  as  is  often  represented,  and 
is  by  no  means  to  be  ignored.  The  liability  to  gastric  cancer 
seems  to  lessen  after  seventy  years  of  age,  but  here  the  number  of 
cases  and  the  number  of  those  living  are  so  small  that  it  is  hazard- 
ous to  draw  positive  conclusions. 

Location. — The  following  table  gives  the  situation  of  the 
tumor  in  1300  cases  of  cancer  of  the  stomach  (from  article  by 
Wm.  H.  Welch,  loc.  cit.) : 


Pyloric 
Region. 

Lesser        ^^^^.^_ 
Curvature. 

Posterior 
Wall. 

Whole  or 

Greater 

Part  of 

Stomach. 

Multiple 
Tumors. 

Greater 
Curvature. 

Anterior       c-„„j,,^ 
Wall.         fundus. 

791 
60.8  % 

148      \        104 

11.4%!     8^ 

68      '        61 
5.2  %        4-7  % 

45 
3-5  % 

34 
2.6  fo 

30                 19 

2.3  %     ,    1.5   % 

From  this  table  it  appears  that  three-fifths  of  all  gastric  cancers 
occupy  the  pyloric  region  ;  but  it  is  not  to  be  understood  that  in 
all  of  these  cases  the  pylorus  itself  is  involved.  In  four-fifths  of 
the  cases  the  comparatively  small  segment  of  the  stomach  repre- 
sented by  the  cardia,  the  lesser  curvature,  and  the  pyloric  region,  is 
the  part  affected  by  gastric  cancer.  The  lesser  curvature  and  the 
anterior  and  posterior  walls  are  involved  more  frequently  than  ap- 
pears from  the  table,  inasmuch  as  many  cancers  assigned  to  the 
pyloric  region  extend  to  these  parts.  The  fundus  is  the  least  fre- 
quent seat  of  cancer.  In  the  cases  classified  as  involving  the 
greater  part  of  the  stomach  the  fundus  often  escapes. 

Frequency. — According  to  Jos.  D.  Bryant,  of  New  York,  ma- 
lignant disease  is  on  the  increase  in  this  country.  The  death-rate 
from  cancer  in  New  York  City  was  1.82  per  cent,  from  1874  to 
1884,  but  from  1884  to  1894  the  death-rate  from  cancer  was  2.17 
per  cent,  of  the  total  mortality  (Jos.  D.  Bryant,  the  "  Wesley  M. 
Carpenter  Lecture,"  New  York  Med.  Journal,  May  18,  1895).  Hae- 
berlin  {Deutsches  Archiv  f.  klin.  Med.,  1889,  Heft  3  and  4)  gives  the 
percentage  of  cancer  of  the  stomach  from  1877  to  1886  as  4.1  per 
cent.  This  writer  has  called  attention  to  the  fact  that  in  Switzer- 
land also  gastric  cancer  is  on  the  increase  ;  his  figures,  showing  the 
death-rate   from  cancer  of  the   stomach  for    looo  inhabitants,  are 


SARCOMA    OF    THE    STOMACH.  •  5  I  I 

the  following:  1877,  0.61  per  cent.;  1878,0.66  per  cent.;  1S79, 
0.72  per  cent.;  1880,  0.77  per  cent.;  1881,  0.85  per  cent.;  1882, 
0.87  per  cent.;  1883,0.85  per  cent.;  1884,0.84  per  cent.;  1885, 
0.90  per  cent.;  1886,  0.99  per  cent.  In  England  the  proportion 
of  deaths  from  cancer  to  the  total  mortality  rate  was  i  in  129, 
in  1840.  This  had  risen  to  i  in  28  in  1880.  The  death-rate  from 
cancer  is  now  about  four  times  as  great  in  England  as  it  was  fifty 
years  ago.  The  published  figures  of  the  Registrar  General's  report 
indicate  that  the  mortality  from  cancer  in  the  years  from  1870  to 
1890  has  increased  53  per  cent,  in  England.  These  facts  are  alarm- 
inpf  and  should  stimulate  the  most  diligent  search  for  the  cause  of 
this  disease. 

(B)  SARCOMATA. 

The  sarcomata  of  the  stomach  are  also  classified  into  two  groups 
according  to  their  origin  ;  namely,  primary  and  secondary.  The 
latter  are  by  far  the  more  rare.  A  single  exception  to  this  rule  is 
the  lymphosarcoma.  The  primary  sarcoma  of  the  gastric  wall 
may  develop  from  any  place  within  the  organ,  but  the  greater  curva- 
ture seems  to  be  preferred,  at  least  by  such  de\"elopment  as  that  in 
which  tumor  nodules  (myosarcoma  and  fibrosarcoma)  are  formed, 
and  in  which  no  extensive  lateral  infiltrations  are  met  with. 

There  is  a  disposition  on  the  part  of  some  authors  (H.  Schle- 
singer,  Zeitschrift  fur  klinisdie  Medicin,  Bd.  xxxii,  Supplement- 
Heft,  p.  179)  to  separate  the  lymphosarcomata,  on  account  of  their 
different  anatomical  relations,  from  the  other  sarcomata.  The  point 
of  issue  of  the  latter  group  is  either  the  muscularis  or  the  sub- 
mucosa,  the  mucosa  not  being  diseased  primarih".  It  may, 
however,  become  injured  in  the  further  progress  by  the  arching 
forward  of  the  tumor  toward  the  interior  of  the  stomach,  resulting 
in  lesions  of  the  mucosa;  in  a  purely  mechanical  way,  from  pulling 
and  stretching  ;  or  it  may  become  ulcerated  toward  the  inner  gas- 
tric cavity.  In  some  cases  the  tumor  may  arch  toward  the  peri- 
toneal cavity.  In  the  center  of  the  sarcomatous  nodules,  particu- 
larly in  the  center  of  myosarcomata,  processes  of  softening  and 
disintegration,  even  of  a  purulent  nature,  may  occur  and  give  rise 
to  septic  peritonitis.  These  tumors  possess  a  spherical  or  an  irregu- 
larly knotty  form,  and  are  attached  by  either  a  broad  or  narrow- 
basis  ;  they  sometimes  attain  vast  dimensions  ( Brodowski  de- 
scribed    a     myosarcoma    weighing    12     pounds).       ^Metastases    in 


512  MALIGNANT    TUMORS    OF    THE    STOMACH. 

neighboring  organs,  particularly  in  the  lymphatic  glands,  greatly 
modify  the  anatomical  picture,  duplicating  as  to  appearances  the 
original  tumor.  The  tumors  that  have  been  observed  so  far  are : 
Spindle-cell  sarcoma  (Hardy,  Weissblum,  Habershon,  Tilger, 
Malvoz) ;  angiosarcoma  (Bruch) ;  myosarcoma  (Virchow,  Kos- 
inski,  Kolisko,  Brodowski);  and  fibrosarcoma  (Tilger,  Ewald, 
Dreyer).  The  majority  of  the  round-celled  sarcomata  that  have 
been  described  (Virchow,  Cayley,  Legg,  Berry,  Shaw,  Drost, 
Rasch)  are  properly  classed  with  the  lymphosarcomata.  W. 
Fleiner  ("  Lehrbuch  der  Krankheiten  der  Verdauungsorgane,"  i, 
Theil,  vide  Magensarcom,  S.  295  und  311)  has  clinically  observed 
one  case  of  lymphosarcoma  and  one  case  of  round-celled  sarcoma, 
and  made  histological  studies  of  the  same  from  the  autopsies ;  and 
H.  Schlesinger  has  given  the  clinical  history  and  undertaken  the 
histological  study  of  two  cases  of  lymphosarcoma  and  one  of 
round-celled  sarcoma  of  the  stomach  {loc.  cit). 

The  primary  lymphosarcomata  of  the  stomach  seem  to  be  rarer 
than  the  secondary  form.  In  some  cases  the  infiltration  is  limited 
mostly  to  the  pyloric  region,  causing  a  rigid  thickening  of  this 
part  (Torok).  In  other  cases  it  occurs  in  enormous  infiltrations 
extending  over  the  whole  stomach,  giving  to  the  inner  surface  the 
appearance  of  a  coarse  swelling  ;  it  may  also  have  the  appearance  of 
a  uniform  infiltration.  The  mucous  membrane  may  be  preserved  for  a 
long  time  in  lymphosarcomata,  but  ulceration  is  not  impossible.  The 
spreading  of  the  disease,  as  is  usual  with  a  lymphosarcoma,  occurs, 
by  the  lymphatic  channels,  those  lymphatic  glands  that  are  nearest 
becoming  diseased  first,  then  the  adjacent  organs,  and,  lastly,  the 
peritoneum.  Sometimes  no  metastases  occur,  as  in  one  case  of 
Kleiner's  ;  more  frequently  lymphosarcomata  are  found  as  second- 
ary neoplasms  in  the  stomach  after  primary  tumors  in  other  organs. 
In  the  cases  of  Kundrat  ("  Ueber  Lymphosarcomatose,"  Wien.  klin. 
Wochenschr.,  1893,  No.  12)  the  original  infected  areas  of  origin 
were  the  neck,  pharynx,  gums,  and  even  the  rectum. 

According  to  other  authors  (Beck  and  Schepelern),  the  cecum, 
and,  in  another  case,  of  Maier's,  the  retroperitoneal  lymph-glands, 
were  the  points  of  origin.  The  gross  anatomical  picture  is  that  of 
infiltrations  in  single  folds  in  the  form  of  thick  plump  wheals,  or  in 
the  form  of  swellings  as  thick  as  the  thumb,  which  ulcerate  or  even 
cicatrize,  yet  seem  to  spare  the  mucosa  for  a  long  time.  The  appa- 
rently normal  parts  of  the  stomach  which  lie  remote  from  the  neo- 


CLIxMCAL    HISTORY    OF    GASTRIC    SARCOMA.  513 

plasm  may  show  a  diffuse,  uniform,  round- celled  infiltration  (Schlag- 
enhauferand  Redtenbacher),  limited  to  the  mucosa  and  submucosa, 
the  glands  themselves  being  compressed,  but  yet  distinctly  pre- 
served. In  a  case  of  Maass'  the  tumor  had  developed  in  the  sub- 
mucosa, the  secretory  layer  was  atrophied,  and  the  glands  were 
strongly  infiltrated  with  small  round  cells.  The  secondary  sarcomata 
of  a  non-lymphosarcomatoustype  are,  as  a  rule,  only  found  accident- 
ally at  the  autopsies,  since  they  develop  only  at  a  late  stage  of  a 
universal  sarcomatosis,  when  the  signs  and  symptoms  are  totally 
obscured  by  others  that  are  more  severe,  and  because  the  nodules 
have  acquired  no  considerable  size.  There  are  no  etiological  fac- 
tors of  importance  known.  The  growth  is  comparatively  rapid 
and  vigorous,  and  Schlesinger  could  determine,  by  palpation, 
extreme  increase  of  size  within  a  few  weeks.  Primary  hmpho- 
sarcomata  may  occur  at  any  age.  Statistics  thus  far  are  too  limited 
to  decide  whether  or  not  sex  is  an  etiological  factor  of  importance. 
Clinically,  it  may  be  said  that  the  beginning  of  the  disease  is  a  \ery 
slow  and  insidious  one,  and,  in  many  cases,  not  marked  by  promi- 
nent gastric  symptoms.  In  other  cases,  anorexia,  a  feeling  of 
fullness,  pressure,  extension,  sour  eructations,  and  a  decomposed 
taste  in  the  mouth,  together  with  progressive  emaciation,  attract 
the  attention  of  the  patient  to  his  condition.  In  many  cases  of 
secondary  sarcoma  no  complaint  referable  to  the  stomach  is  made. 
The  appetite  may  be  good  for  a  longtime;  hemorrhages  ma\' be 
absent  in  the  incipient  stages  because  the  neoplasm  has  not  yet 
taken  on  ulceration.  Gradually  the  symptoms  become  severer,  the 
anorexia  becomes  pronounced,  and  vomiting  is  more  frequent;  the 
vomit  smells  sour  and  is  decomposed,  and  occasionally  has  the  ap- 
pearance of  coffee  grounds.  Admixtures  of  a  coffee-groimd  nature 
were  present  in  the  stools  in  all  of  Schlesinger's  cases,  which  were 
mostly  accompanied  by  diarrhea.  Sometimes  a  neoplasm  can  not  be 
demonstrated  even  in  the  later  stages;  but  when  a  tumor  is  palpable, 
it  is  painful  to  pressure  and  behaves  similar  to  carcinomatous 
gastric  tumors  regarding  motility.  Dilatation  may  exist,  according 
to  Kundrat  and  Schlesinger,  without  stenosis  of  the  pylorus,  and  a 
general  tetany  may  eventually  result  exactly  as  in  other  cases  of 
pyloric  stenosis.  If  the  lymphosarcoma  is  located  at  the  p\-lorus, 
it  is  distinctly  palpable  and  causes  secondary  dilatation  with  motor 
insufficiency.  Fleiner,  Schlesinger,  Dreyer,  ]\Iaass,  and  Hammer- 
schlag,  found  absence  of  HCl  and  presence  of  lactic  acid,  with 
34 


514  MALIGNANT    TUMORS    OF    THE    STOMACH. 

enormous  numbers  of  yeast  and  other  bacteria  but  no  sarcinse. 
H.  Schlesinger,  in  two  of  his  cases  {loc.  cit.),  found  the  long, 
immotile  bacilli,  which  were  pronounced  by  Kauffmann  and 
W.  Schlesinger  to  be  characteristic  of  lactic  acid  fermentation  (see 
illustration,  p.  1 19).  There  seems  to  be  a  constant  enlargement  of 
the  spleen  with  primary  as  well  as  with  secondary  sarcomata  and 
lymphosarcomata.  This  is  a  rare  occurrence  with  the  carcinomata, 
and  might  therefore  be  of  value  in  a  differential  diagnosis.  Von 
Leube  cautions  against  making  a  diagnosis  of  gastric  sarcoma.  In 
one  case  of  universal  sarcomatosis  of  the  skin  he  found  a  genuine 
epithelial  carcinoma  in  the  stomach. 

From  what  has  been  said,  it  is  evident  that  no  important  clinical 
factors  can  be  drawn  from  the  local  signs  and  symptoms,  nor  from 
the  general  condition  of  the  blood,  urine,  and  the  general  state  of 
health,  for  the  establishment  of  differential  diagnosis  between 
carcinoma  and  sarcoma  of  the  stomach.  Regarding  the  prognosis 
and  treatment,  therefore,  we  refer  to  these  headings  as  they  are 
considered  under  carcinoma  of  the  stomach. 

Symptomatology. — What  is  said  here  on  symptomatology  has 
reference  to  all  neoplasms  of  the  stomach.  In  a  small  number  of 
cases  the  development  of  malignant  growth  of  the  stomach  remains 
entirely  latent,  because  every  typical  gastric  symptom  is  wanting 
until  death.  As  far  as  we  have  had  occasion  to  observe,  the  first 
symptoms  of  a  gastric  carcinoma  are  those  of  chronic  gastritis. 

Most  of  these  patients  state  that,  up  to  the  time  of  their  disease, 
they  enjoyed  a  very  good,  sound  stomach.  The  first  d}\speptic 
complaints  are  those  of  pressure  and  fullness  in  the  gastric  region, 
eructations,  anorexia,  nausea,  vomiting,  cardialgia,  anomalies  in 
the  secretion,  absorption,  motility,  and  coated  tongue.  Disturb- 
ances of  sensibility  are  not  felt  until  the  neoplasm  has  reached  a 
certain  size,  thereby  exerting  pressure  on  the  sensory  nerves  of 
the  stomach  ;  or  when,  by  its  ulcerations,  or  by  the  irritation  of 
the  digestive  juices,  these  nerves  have  been  exposed.  The  patient 
has  a  sensation  as  if  a  stone  were  lying  in  his  stomach,  some- 
times complaining  of  unpleasant  feelings  of  emptiness,  which  come 
both  a  var}'ing  time  after  eating  as  well  as  on  an  empty  stomach, 
and  not  rarely  continue  an  entire  day,  so  that  the  patient  is  con- 
stantly reminded  of  his  stomach,  which  he  was  not  aware  of  for- 
merly, and  is  placed  in  that  characteristic  despondent  and  melan- 
choly mood  frequently  met  with  in  gastric  sufferers.     These  sen- 


PERISTALSIS,  SECRETION,  AND  ABSORPTION  IN   CARCINOMA.        515 

sations  may  increase  to  actual  pain,  which,  however,  are  not  so 
severe  as  in  ulcer.  Eructations  are  present  in  the  beginning  of 
gastric  ulcer  as  well  as  later  on,  either  bringing  up  air  or  small 
particles  of  the  gastric  contents,  which  have  a  bitter  taste ;  but  later 
on,  when,  in  consequence  of  achylia,  the  stagnating  gastric  ingesta 
ferment  more  and  more,  the  eructated  gas  may  have  a  disgusting, 
decomposed  odor  and  taste. 

Pyrosis  may  be  present,  and  is,  as  a  rule,  accompanied  by  excess  of 
organic  acids.  Singultus  occasionally  accompanies  the  eructations, 
and  is  observed  most  frequently  with  carcinoma  of  the  cardia.  In 
rare  cases  (Ebstein  and  Eichhorst)  there  ma}-  be  a  tetan}-  of  the  con- 
strictor muscles  of  the  pharynx,  which  is  said  to  be  caused  reflexly 
from  the  stomach,  and  may  prevent  ingestion  of  food.  The  fre- 
quency of  nausea  and  vomiting  depends  upon  the  location  of  the 
tumor  in  the  stomach  ;  they  are  never  absent  when  the  neoplasm 
is  located  at  the  cardia  or  pylorus.  The  nature  and  chemical  con- 
dition of  the  vomited  matter  depend  upon  the  time  of  the  emesis 
and  the  degree  of  secretory  disturbance  as  well  as  upon  the  extent 
of  the  gastritis,  and  may  consist  of  more  or  less  altered  ingesta, 
decomposed  food  remnants,  mucus,  blood,  or  bile.  Advanced  de- 
composition is  not  observed  until  a  late  period  of  the  growth.  The 
vomited  masses  are  rich  in  bacteria  and  contain  the  Oppler-Boas 
bacilli,  which  are  characteristic  of  lactic  acid  fermentation,  though  not 
pathognomonic  of  cancer  (p.  119).  The  tongue  nearly  always  has  a 
brownish-yellow  or  grayish-white  coating,  but  may  be  quite  clean 
after  profuse  vomiting.  The  taste  is  said  to  be  pasty,  bitter,  or 
offensive  in  the  last  stages,  and  salivation  and  thirst  are  increased. 
The  loss  of  appetite  belongs  to  the  earliest  symptoms,  with  par- 
ticular dislike  for  meat  at  all  stages  of  the  disease.  In  some  patients 
complete  anorexia  alternates  with  bulimia.  As  a  rule,  appetite 
remains  fair  as  long  as  there  is  any  gastric  secretion,  or  as  long  as 
the  motility  remains  fairly  good. 

Disturbances  of  Peristalsis,  Secretion,  and  Absorption. — These  are 
caused  by  chronic  gastritis,  anemia,  or  direct  extension  of  the  neo- 
plasm into  the  mucosa  and  muscularis  of  the  stomach.  The  dis- 
turbances of  motility  are  either  due  to  destruction  of  the  muscularis 
or  invasion  of  the  gastric  neoplasm,  or  to  stenosis  at  the  pylorus. 
We  do  not  believe  that  they  are  traceable  to  the  induced  gastritis, 
because  in  chronic  gastritis,  according  to  very  careful  observations, 
the   motility  in   the    majority  of  cases   is    not  very  seriously  inter- 


5l6  MALIGNANT    TUMORS    OF    THE    STOMACH. 

fered  with.  Accordingly,  we  find  that  in  three  to  four  hours  after 
the  test-breakfast,  or  eight  to  ten  hours  after  a  full  test-dinner,  when 
the  stomach  normally  should  be  empty,  an  abundance  of  food 
remnants  is  contained  in  it.  In  cases  where  the  neoplasm  is  not 
located  at  either  orifice  of  the  stomach,  the  motility  remains  good 
for  a  long  time,  and  even  in  the  absence  of  secretion  of  HCl,  the 
vicarious  digestion  of  the  intestines  is  sufficient  to  make  up  for  the 
loss  of  gastric  digestion  and  to  avoid  emaciation. 

If  it  is  desired  to  test  motility  in  gastric  carcinoma  by  means  of 
our  method, — that  is,  by  the  "  deglutable  india-rubber  stomach- 
shaped  bag," — it  is  wise  not  to  distend  the  bag  too  much  ;  in  fact, 
in  cases  of  advanced  cancer,  the  use  of  any  intragastric  instrument 
except  the  stomach-tube  for  this  purpose  is  unjustifiable,  because, 
in  our  experience,  the  stomach-tube,  with  the  help  of  previous 
test-meals,  has  been  found  perfectly  sufficient  to  ascertain  the  con- 
dition of  the  motility  in  this  disease.  The  loss  of  secretion  in 
gastric  cancer  was  first  discovered  by  von  der  Velden  [Deiitsch. 
Arch.f.  klin.  Med.,  Bd.  xxiii,  p.  369,  1879).  The  great  diagnostic 
value  of  the  absence  of  free  HCl  in  the  gastric  contents  in  malig- 
nant neoplasm  is  to-day  universally  admitted.  There  are  other 
diseases  (atrophic  gastritis  and  achylia  gastrica)  in  which  free  HCl 
is  wanting,  but  it  is  one  of  the  most  constant  symptoms  of  gastric 
cancer.  Only  in  the  carcinoma  that  arises  from  an  ulcer  do  we 
find  HCl  present,  and  this  is,  in  our  opinion,  explained  by  the  fact 
that  ulcus  carcinomatosum  is,  in  the  great  majority  of  cases,  re- 
ported a  very  localized  affection  with  little  or  no  disseminating  in- 
filtration. We  should  not  conclude  our  study  of  the  secretory 
function  by  merely  testing  for  free  HCl.  In  all  critical  cases  an 
artificial  digestion  experiment  should  be  made  with  egg-albumen 
discs,  as  described  in  the  first  part  of  this  work',  and  the  amount 
of  the  HCl  deficit  determined.  The  Jaworski  method  should 
not  be  neglected  in  testing  for  the  gastric  ferments.  About  200 
c.c.  of  a  five  per  1000  solution  of  HCl  are  poured  into  the  stomach, 
after  it  has  been  previously  cleansed,  and  a  quantity  redrawn  in 
twenty  minutes;  if  this  does  not  digest  egg-albumen  after  a  further 
addition  of  HCl,  and  no  rennin-zymogen  is  contained  in  it,  then 
the  glandular  activity  is  completely  extinguished.  The  state  of 
the  resorption  is  very  much  reduced,  according  to  Eichhorst,  Zwei- 
fel,  Wolff,  and  others.  Capsules  of  three  to  five  grs.  of  iodid  of 
potash,  which  should  give   the   iodin  reaction  in  the   saliva  fifteen 


STATE    OF    BLOOD    AND    URINE    IN    CARCINOMA.  517 

minutes  after  they  are  swallowed,  do  not,  as  a  rule,  give  this  re- 
action before  one  hour  to  one  and  a  half  hours  have  expired. 

The  effects  of  gastric  carcinoma  on  the  blood  can  be  easily 
recognized  by  blood  examinations  and  staining  of  blood  preparations 
for  the  microscope,  as  described  by  Dr.  Whitney  in  the  section  de- 
voted to  this  matter.  With  the  progressive  cachexia,  the  color  of 
the  face  and  of  the  external  mucous  membrane  becomes  pale  or 
yellowish.  There  is  persistent  insomnia,  and,  as  a  consequence  of  the 
hydremia  and  the  impoverished  condition,  the  vessel  walls  become 
more  permeable,  producing  the  frequent  edemas  at  the  ankles  and 
other  dependent  parts  which  sometimes  invoke  suspicion  of 
nephritis.  The  body  weight  may  be  reduced  30  to  40  pounds -in 
from  one  to  two  months.  The  urine  is  greatly  diminished  in  quan- 
tity, concentrated,  and  highly  colored,  as  a  result  of  the  impaired 
absorption,  frequent  emesis,  and  edemas.  The  reaction  is  neutral 
or  even  alkaline,  particularly  if,  by  methodical  lavage,  the  acids 
and  acid  salts  have  been  largely  removed.  If  constipation  exists, 
an  excess  of  indican  is  found  in  the  urine;  this  is  conveniently 
tested  for  by  adding  to  ten  c.c.  of  the  urine  an  equal  amount  of 
concentrated  hydrochloric  acid  and  one  c.c.  of  chloroform.  One 
drop  of  calcium  hypochlorite  solution  is  then  added,  and  the  mix- 
ture shaken.  During  the  ensuing  oxidation  the  indigo  which  is 
formed  is  dissolved  in  the  chloroform  ;  a  strong  bluish  discoloration 
is  a  pathological  indication.  If  the  urine  is  highly  colored,  or  con- 
tains much  albumin,  it  is  advantageously  cleared  of  this  product 
by  treatment  with  plumbic  acetate,  and  the  filtrate  used  as  just 
stated. 

Von  Jaksch  demonstrated  the  presence  of  acetone  in  the  urine, 
and  Maixner  discovered  peptone  in  the  urine  of  12  cases  he  exam- 
ined, and  his  results  were  confirmed  by  Parganowski.  Maixner 
attributes  the  peptonuria  to  impairment  of  the  ability  of  the  gas- 
tric membrane  to  change  peptone  back  into  albumin,  while  Par- 
ganowski believes  that  the  formation  of  the  peptone  takes  place  in 
the  disintegrating  cancerous  tissue.  The  urine  also  gives  a  Bur- 
gundy-red color  with  chlorid  of  iron,  which  is  probably  due  to 
diacetic  acid.  The  feces  frequently  contain  undigested  muscle- 
fibers  and  egg-albumen  taken  in  the  food.  There  is  usually  very 
pronounced  constipation,  which  is  caused  by  two  principal  factors, 
namely,  the  greater  amount  of  work  that  the  intestine  is  called 
upon  to  perform  and  the  impaired  peristalsis. 


5l8  MALIGNANT    TUMORS    OF    THE    STOMACH. 

Special  Symptoms. — Hcuiateuiesis. — The  hemorrhages  from 
gastric  carcinoma  are,  as  a  rule,  not  abundant,  although  they  are  quite 
frequent.  They  are  most  frequently  observed  in  carcinoma  of 
the  pylorus  and  of  the  lesser  curvature.  As  hemorrhages  which 
are  not  copious  do  not  easily  lead  to  emesis,  there  is  sufficient  time 
for  changing  of  the  blood  pigments  into  hematin,  which  is  uni- 
formly mixed  with  the  gastric  contents,  so  that  when  they  are 
eventually  vomited  they  present  the  appearance  of  coffee  grounds 
or  dark  chocolate,  which  is,  according  to  Brinton,  a  vomit  that  is 
observed  in  about  42  per  cent,  of  the  cases,  and  is,  therefore,  an 
important  sign  in  gastric  cancer.  This  kind  of  vomit  may  also 
occur  in  chronic  passive  congestion  of  the  stomach  and  in  ulcer. 
In  chronic  gastritis  one  rarely  meets  with  coffee-ground  vomit, 
but  the  ingesta  show  simply  streaks  or  points  of  blood.  If  the 
coffee-ground  admixture  in  vomit  occurs  frequently  or  daily  for 
weeks,  then  it  becomes  an  important  pathognomonic  symptom  of 
gastric  malignant  neoplasm. 

The  Occurrence  and  Determination  of  Tumor. — In  all  cases 
of  suspected  carcinoma  of  the  stomach  the  examining  physician 
should  carefully  and  systematically  go  through  the  routine  of 
inspection,  palpation,  percussion,  and  artificial  distention  of  the 
stomach  by  air  or  gas.  When  an  abdominal  tumor  is  formed  by 
the  dilated  stomach  itself,  the  diagnosis,  in  the  majority  of  cases, 
can  be  made  by  a  simple  inspection.  To  determine  the  presence 
of  peristalsis  in  dilated  stomachs,  rarely  anything  else  than  close 
inspection  is  necessary. 

There  are  two  conditions  in  which  the  stomach  itself  may  form 
a  palpable  tumor  by  chronic  contraction  :  one  is  where  the 
organ  shrinks  in  consequence  of  occlusion  of  the  esophagus, 
and  can  be  felt  as  a  narrow  firm  ridge  lying  below  the  left  lobe  of 
the  liver;  the  other  condition  is  known  as  cirrhosis  ventriculi,  and 
is  the  result  of  chronic  hyperplasia  of  the  walls,  with  subsequent 
contraction  of  the  lumen.  In  very  rare  instances  it  might  be  caused 
by  diffuse  carcinomatous  infiltration.  The  infiltrating  scirrhous  car- 
cinoma of  the  stomach,  even  at  the  autopsy,  may  not  be  distin- 
guishable microscopically  from  cirrhosis  of  the  organ.  In  this 
instance  we  are  concerned  most  directly  with  the  nodular  and 
massive  tumors  of  the  stomach. 

As  three-fifths  of  all  tumors  occupy  the  pyloric  region,  and  as 
the  normal  pylorus  is  palpable  through  the  abdominal  walls,  these 


DIAGNOSIS    OF    GASTRIC    TUMORS.  5  I9 

tumors  should  not  escape  diagnostic  palpation.  For,  when  the 
stomach  is  filled  with  food  or  water,  distended  by  gas,  or  in  a 
state  of  atony,  the  pylorus  is  always  below  the  edge  of  the  liver. 
In  some  cases  where  the  abdominal  walls  are  not  too  thick,  it  is 
possible  to  feel  and  recognize  the  normal  pylorus  as  a  small,  trans- 
versely placed  ridge,  which  varies  its  position  with  respiration. 
Personally,  we  have  frequently  been  able  to  grasp  the  normal 
pylorus  between  the  fingers  of  the  left  hand,  and,  by  massage  and 
compression  of  the  fundus  by  the  right  hand,  we  have  been  able  to 
recognize  the  escape  of  air  and  liquid  ingesta  through  the  pyloric 
ring.  The  detection  of  the  location  of  the  pylorus  is  easier  in 
dyspeptic  patients  than  in  the  normal  state,  because  in  cases  in 
which  it  becomes  important  to  recognize  the  pylorus  there  is  gen- 
erally considerable  emaciation  of  the  abdominal  walls,  thus  facili- 
tating palpation.  Alternating  relaxation  and  contraction  of  the 
pylorus  may  sometimes  be  felt,  but  this  phenomenon  is  very  rare. 
Osier,  in  his  "Practical  Monograph  on  the  Diagnosis  of  Abdominal 
Tumors  "  (D.  Appleton  &  Co.,  1 894)  sums  up  the  leading  points  con- 
cerning the  solid  tumors  of  the  stomach  in  the  following  terms: 
"  Though  only  a  small  section  of  the  stomach  is  available  for 
palpation,  a  very  large  proportion  of  all  tumors  of  the  organ  may 
be  felt,  owing  in  part  to  their  greater  frequency  at  the  p}'loric  por- 
tion, and  in  part  owing  to  the  frequent  depression  of  the  organ." 
He  gives  an  account  of  24  cases,  in  all  of  which  a  tumor  or  indu- 
ration was  detected.  In  the  majority  of  the  cases  no  trouble  was 
experienced  in  determining  whether  or  not  a  tumor  was  in  the 
stomach.  Excessive  mobility  of  a  pyloric  growth  and  extensive 
infiltrating  masses  in  the  epigastric  region  were  the  only  condi- 
tions causing  trouble,  in  any  of  the  cases  of  his  series.  As  other 
forms  of  tumor  of  the  stomach  (those  that  we  have  referred  to  in 
the  sections  on  Malignant  and  Benign  Tumors)  are  rare,  a  palpable 
tumor  in  the  stomach  may,  as  a  rule,  be  considered  a  carcinoma. 
One  can  not  exclude  carcinoma  even  when  a  palpable  tumor  is 
absent,  because  20  per  cent,  of  all  cases  escape  objective  demon- 
stration during  their  entire  clinical  history  (Fleischer).  Among 
these  cases  we  must  reckon  the  cancers  affecting  the  cardia,  the 
lesser  curvature,  and  part  of  those  affecting  the  posterior  w^all.  In 
order  to  instruct  ourselves  concerning  the  typical  peculiarities  of  a 
tumor,  and  to  avoid  confounding  it  with  neoplasms  of  adjacent 
organs,  repeated  and  thorough  examinations  are  necessary.     The 


520  MALIGNANT   TUMORS    OF   THE    STOMACH. 

patient  should  be  placed  in  a  horizontal  position,  his  knees  should  be 
flexed  and  his  mouth  kept  open,  and  palpation  should  be  careful  and 
gentle,  because  energetic  and  rapid  palpation  does  more  harm  than 
good,  as  it  produces  an  annoying  tension  of  the  abdominal  mus- 
cles. We  are  in  the  habit  of  evacuating  the  stomach  by  lavage, 
and  also  the  entire  intestinal  tract  by  a  purge,  prior  to  palpation  in 
order  to  bring  about  the  most  favorable  conditions  for  this  exami- 
nation. 

Occasionally,  a  tumor  will  be  evident  upon  simple  inspection  as 
a  round  or  oval  prominence,  but  the  results  of  palpation  are  more 
reliable.  The  cancer  can  be  felt  as  a  hard,  uneven,  sharply  circum- 
scribed, nodular  tumor.  When  the  growth  has  extended  more 
toward  the  interior  of  the  stomach  and  brought  about  diffuse  infil- 
trations, one  feels  a  more  uniform  and  frequently  only  an  indistinct 
resistance  toward  the  depths  of  the  epigastrium  or  right  hypochon- 
drium.  In  the  beginning  of  a  carcinomatous  growth  at  the  pylorus, 
its  smooth  contour  will  not  permit  of  a  sure  differentiation  from 
benign  hypertrophy,  especially  as  the  consecutive  symptoms  of 
stenosis,  gastritis,  and  dilatation  are  coincident  with  both.  In  this 
case  the  only  means  of  reaching  a  decision  is  by  watching  the 
further  progress  of  the  tumor.  When  the  stomach  is  filled  with 
food  and  gases  the  tumor  is  less  distinct  on  palpation.  If  the  tumor 
mass  rapidly  disintegrates,  without  perforation,  it  may  permanently 
disappear.  Persistent  and  stubborn  reflex  cramp  of  the  pylorus 
may  give  the  impression  of  carcinoma.  In  a  case  reported  from 
Leube's  clinic,  in  a  man  aged  thirty-six  years,  who  had  a  dilatation 
and  a  distinctly  palpable  tumor  in  the  umbilical  region,  an  opera- 
tion was  decided  upon,  but  when  von  Heinecke  and  Leube  re-ex- 
amined the  man  under  chloroform  anesthesia,  the  tumor  had 
disappeared ;  the  patient  was  consequently  not  operated  upon,  and 
was  reported  living  in  good  health  twelve  years  after  this  experience. 

Position  and  Movability  of  the  Tumor. — Five-sixths  of  the 
normal  stomach  is  located  in  the  left  half  of  the  abdomen ;  there- 
fore, gastric  tumors  are  generally  palpable  in  the  epigastrium  a  little 
to  the  left — very  rarely  to  the  right — of  the  median  line,  and  above 
the  umbilicus.  Later  on,  the  tumor  sinks  downward  more  and  more 
and  can  be  demonstrated  below  the  umbilicus,  particularly  if  it  be 
a  pyloric  neoplasm.  If  no  adhesions  exist,  it  may  even  sink  down 
into  the  pelvis.  When  there  are  adhesions  near  the  locality  of  the 
tumor   it  is  immovable,  but  if  they  are  absent  the  tumor  may  be 


POSITION    AND    MOVABILITY    OF    TUMORS.  521 

moved  to  and  fro  to  some  extent.  In  the  article  referred  to,  Osier 
gives  some  clear  illustrations  of  the  positions  into  which  gastric 
tumors  can  be  moved.  Changing  the  position  of  the  body  brings 
about~a  moderate  movement  in  the  growth.  In  order  to  ascertain 
whether  a  tumor  belongs  to  the  stomach  proper,  the  changes  in 
form  and  position  of  the  organ,  which  are  caused  by  filling  the 
same  with  water  or  distending  it  with  air,  are  very  helpful.  If  on 
filling  the  stomach  with  water  the  tumor  lies  within  the  area  of 
dullness  thus  artificially  produced,  and  if  on  subsequent  distention 
of  the  stomach  with  COo  a  tympanitic  resonance  can  be  made  out 
above  and  below  the  tumor,  it  belongs  to  the  stomach.  On  filling 
the  colon  with  one  to  two  liters  of  water  the  gastric  tumors  rise 
upward,  and  may  hide  behind  the  liver  and  sternum.  It  is  gener- 
ally stated  that  gastric  tumors,  in  the  majority  of  cases,  do  not  move 
with  respiration,  but  that  tumors  of  the  liver  do.  There  are  many 
exceptions  to  this  rule.  If  there  are  any  adhesions  to  the  liver, 
spleen,  or  diaphragm,  stomach  neoplasms  participate  in  the  respira- 
tory movements  of  these  organs.  If  the  tumor  is  of  considerable 
size  it  moves  downward  with  respiration,  because  it  can  not  get  out 
of  the  way  of  the  descending  diaphragm.  The  percussion  note 
over  the  tumor  is  most  frequently  of  a  dull  tympanitic  character. 
It  has  been  stated  that  hepatic  tumors  give  only  a  dullness  on  per- 
cussion, and  that  this  may  serve  to  differentiate  them  from  the 
stomach  tumors  ;  this  however,  is  a  misleading  sign,  because  large 
gastric  tumors  will  give  dullness  on  percussion,  and  if  a  hepatic 
tumor  is  located  at  the  margin  of  the  liver,  or  if  a  few  loops  of  in- 
testine or  the  colon  lie  between  it  and  the  abdominal  wall,  a  tym- 
panitic percussion  note  will  result.  Pulsations  may  be  evident  in 
tumors  that  are  adjacent  to  the  celiac  axis  or  superimposed  upon 
the  aorta.  If  the  latter  is  compressed  by  the  tumor,  the  tonicity  of 
the  crural  pulse  is  diminished,  and  the  epigastric  growth  may  mimic 
an  aneurysm. 

Differentiation  of  Gastric  Tumors  from  those  of  Adjoining 
Organs. — {a)  From  Splenic  Tumors. — As  gastric  cancers  rarely 
occur  at  the  fundus,  their  differentiation  from  splenic  tumor  is  rarely 
called  for,  and  is  seldom  difficult.  The  spleen  is  movable  with  respi- 
ration; the  stomach  only  exceptionally.  In  splenic  tumor  we 
have  dullness  on  percussion,  absence  of  d\'speptic  S}-mptoms,  and 
disturbance  of  gastric  function.  In  gastric  tumor  we  have  a  tym- 
panitic resonance  on  percussion  and  disturbances  of  secretion  and 


522  MALIGNANT    TUMORS    OF    THE   STOMACH. 

motility.     Splenic  tumors  can  be  very  often  mapped  out  and  found 
to  be  ascending  back  of  the  ribs. 

[b)  From  Tumor  of  the  Liver. — Hepatic  tumors  move  with  respira- 
tion, and  frequently  it  is  possible  to  grasp  the  gastric  tumor  and 
separate  it  from  the  liver.  The  contours  of  the  liver  should  be 
determined,  if  possible  ;  for  with  hepatic  tumors  the  liver  is  generally 
enlarged  and  sensitive  to  pressure,  and  the  surface  is  frequently 
uneven.  Phenomena  of  disturbance  of  hepatic  circulation,  such  as 
icterus  and  ascites,  denote  liver  tumor.  It  is  true  that  dyspeptic 
symptoms  may  be  secondarily  caused  by  malignant  disease  of  the 
liver;  but  then  they  present  themselves  later  in  the  disease,  with 
gastric  cancer;  dyspeptic  symptoms  are  among  the  very  first.* 

[c)  From  Malignant  and  other  Ttimors  of  the  Gall-bladder. — Carci- 
noma of  the  gall-bladder  and  accumulations  of  gall-stones  may  be 
confounded  with  pyloric  carcinoma.  The  latter  brings  on  gastric 
dilatation  and  grave  anomalies  of  function,  which  are  absent  in 
afifections  of  the  gall-bladder.  Cancers  of  the  gall-bladder  are  not 
secondary  to  cancers  of  the  stomach,  as  a  rule.  If,  however,  the 
gall-bladder  tumor  presses  upon  the  pylorus,  and  also  causes 
stenosis  and  dilatation,  as  we  had  occasion  to  observe  at  an  autopsy 
in  the  Maryland  General  Hospital,  December,  1896,  the  differen- 
tiation from  gastric  neoplasm  is  practically  impossible.  The  asser- 
tion that  hydrochloric  acid  is  still  secreted  when  the  carcinoma  is 
in  the  gall-bladder  and  not  in  the  stomach,  is  not  supported  by 
sufficient  evidence,  because  passive  congestion  concomitant  with 
gall-bladder  and  hepatic  tumors  often  brings  about  loss  of  gastric 
secretion. 

[d)  Carcinoma  of  the  pancreas  has  frequently  deceived  clinicians 
in  the  diagnosis  of  abdominal  tumors.  Its  immovability  during 
respiration  and  palpation  might  suggest  pyloric  carcinoma;  pan- 
creatic tumors,  however,  frequently  cause  stasis  in  the  portal  vein 
and  pronounced  icterus,  while  dyspeptic  disturbances  and  loss  of 
HCl,  which  are  early  and  prominent  symptoms  of  gastric  cancer, 
are  absent. 

{e)  Tumors  of  the  Omentum  and  Peritoneum. — The  differentiation 
of  these  tumors  from  gastric  carcinoma  is  difficult  when  symptoms 
of  disturbed  gastric  digestion  are  present  and  the  tumor  does  not 
exceed  the  limits  of  the  stomach.     As  a  rule,  these  tumors,  being 

*  The  liver  itself  may  give  the  signs  and  symptoms  of  a  tumor  (see  chapter  on 
Enteroptosis). 


DIFFERENTIATION    OF    ABDOMINAL   TUMORS.  523 

secondary,  are  not  so  sharply  circumscribed  as  gastric  tumors. 
Ascites  is  rarely  absent.  The  original  source — the  primary  tumor 
in  some  other  organ — should,  if  possible,  be  found  out.  Sometimes 
disease  of  the  stomach  may  be  excluded  by  known  analytical 
methods,  and  then  the  diagnosis  becomes  possible. 

(/")  Tumors  of  the  colon,  as  a  rule,  sink  downward,  because  the 
colon  is  very  movable,  unless  (very  rarely)  adhesions  form  with 
the  abdominal  wall.  By  alternately  filling  the  stomach  with  water 
and  air,  and  subsequently  evacuating  it  again,  it  may  be  demon- 
strated that  the  tumor  is  independent  of  the  stomach.  When  the 
colon  is  filled  with  one  to  two  liters  of  water,  the  tumor  rises  but 
very  slightly,  if  at  all ;  while  tumors  of  the  stomach,  on  filling  the 
colon,  generally  ascend,  and  may  disappear  behind  the  liver  or 
sternum.  Tumors  of  the  anterior  wall  of  the  colon  become  more 
distinct  when  it  is  filled  with  water,  while  those  of  the  posterior 
wall  become  less  distinct.  A  stenosis,  as  a  rule,  appears  promptly, 
and  the  colon  becomes  tremendously  expanded  in  front  of  the  con- 
striction. Osier  {loc.  cit?)  has  reported  a  carcinoma  of  the  cecum 
and  colon,  with  enormous  secondary  enlargement  of  the  liver,  and 
extensive  secondary  nodules  were  scattered  through  the  lungs. 
His  case  is  very  instructive,  as  the  intestinal  symptoms  were 
absent,  thus  illustrating  the  ease  with  which  an  erroneous  diagnosis 
may  be  made. 

{g)  Duodenal  carcinoma  can  scarcely  be  separated  from  pyloric 
carcinoma.  The  occurrence  of  a  tumor  in  the  vicinity  of  the  um- 
bilicus, the  cachexia,  the  consecutive  gastric  dilatation,  and  (if  the 
duodenal  carcinoma  should  ulcerate)  the  coffee-ground  vomit — all 
these  signs  may  be  present  in  cancers  of  either  locality.  If  free 
HCl  can  be  demonstrated  in  the  gastric  contents,  or  its  secretion 
can  be  caused  after  methodical  lavage,  the  other  symptoms  of  neo- 
plasm might  possibly  be  referred  to  the  duodenum.  Carcinoma  of 
the  duodenum,  as  Ewald  and  Riegel  have  shown,  may  be  com- 
bined with  atrophic  gastritis,  so  that  absence  of  HCl  may,  in  these 
cases,  occur,  which  absence  is  not  directly  caused  by  a  gastric  car- 
cinoma; hence,  the  diagnosis  is  largely  a  matter  of  chance.  It  is 
evident  that  a  thorough  knowledge  of  gastric  cancer  and  the  ap- 
plication of  all  physical  and  chemical  methods  of  diagnosis  are 
necessary  if  we  wish  to  be  approximately  correct  in  our  diagnosis. 
In  all  cases  of  doubtful  differential  diagnosis  exploratory  laparo- 
tomy should  not  be  deferred  until  the  loss  of  strength  of  the  patient 
contra-indicates  the  operation. 


524  MALIGNANT    TUMORS    OF    THE    STOMACH. 

Cachexia. — As  the  gastric  cancer  progresses,  anemia  and  ema- 
ciation increase  to  a  pronounced  cachexia.  The  color  of  the  skin 
becomes  grayish-white  or  yellow  ;  it  may  appear  wrinkly,  atrophic, 
and  exfoliating.  Frequently  an  annoying  pruritus  is  present.  The 
body  weight  becomes  less  and  less  ;  the  more  digestion  is  disturbed, 
the  severer  the  vomiting,  and  the  more  the  passage  of  chyme  into 
the  intestine  becomes  obstructed.  The  blood  grows  poorer  in  red 
blood-corpuscles  and  in  hemoglobin,  and  a  state  similar  to  perni- 
cious anemia  may  result.  Pronounced  diminution  of  the  hemo- 
globin is  such  a  constant  accompaniment  of  gastric  cancer  that  it 
can  almost  be  excluded  in  case  the  amount  of  hemoglobin  is  equal 
to  60  per  cent,  or  more  (Haberlin-Eichhorst).  The  amount  may 
sink  to  40  and  30  per  cent.  In  one  case  of  Eichhorst's  it  sank  to 
ten  per  cent.  Accidental  sounds  about  the  heart  and  signs  of  cere- 
bral anemia  or  of  moderate  edema  have  been  observed.  Ascites  is 
a  consequence  of  secondary  metastases  in  the  liver  or  peritoneum, 
or  of  thrombosis  in  the  portal  vein  ;  but  toward  the  end  of  life  it 
may  be  caused  by  great  cardiac  asthenia  and  hydremia.  Thrombosis 
of  the  main  vessels  of  one  leg  has  been  observed,  and  constitutes  a 
very  fatal  sign.  The  pulse  is  mostly  accelerated  and  the  body 
temperature  subnormal.  Fever  is  a  rare  occurrence  in  gastric  can- 
cer ;  if  it  does  occur,  it  is  traceable  to  auto-intoxication  with  septic 
products  formed   in  the   ulceration  or  degeneration  of  the  cancer. 

Coma  carcinomatosum  is  a  complication  of  symptoms  similar 
to  the  coma  of  diabetics,  and  is  accompanied  by  a  peculiar  dyspnea. 
The  respirations  are  strong  and  deep,  and  generally  attended  with 
a  groaning  sound  in  expiration.  The  rate  of  respiration  is  either 
normal  or  moderately  increased.  The  temperature  is  either  nor- 
mal or  subnormal.  There  is  no  evidence  of  disease  of  the  lungs  or 
air  passages.  It  does  not  usually  appear  until  anemia  is  far 
advanced.  This  kind  of  coma  was  first  described  by  Fetters  and 
Kaulich,  and  later  by  von  Jaksch  (Wien.  med.  Wocliensclir.,  1883, 
p.  473).  This  coma  is  probably  a  consequence  of  auto-intoxication 
by  products  of  abnormal  decomposition.  (See  literature  of  this  sub- 
ject in  Albu,  "  Autointoxicationen  des  Intestinaltractus,"  Berlin, 
189s,  p.  105.) 

As  we  have  stated  in  the  pathology  of  carcinoma,  swellings  of 
the  peripheral  lymph-glands  are  not  rare.  A  hard  swelling  of  the 
supraclavicular  glands  was  considered  typical  by  Friedreich  and 
Henoch.  If  severe  vomiting  ceases  suddenly,  a  breaking  down  of 
the  cancerous  infiltration  of  tlie  pyloric  region  may  be  inferred,  by 


CARCINOMATOUS    ULCER.  525 

which  communication  with  the  intestines  maybe  restored,  or  it  may 
be  due  to  excessive  muscular  insufficiency. 

Carcinomatous  Ulcer  (Ulcus  Carcinomatosum). — We  have 
already  stated,  in  the  section  on  the  Pathology  of  Gastric  Ulcer,  that 
atypical  cell-proliferation  may  develop  from  a  benign  gastric  ulcer, 
which  thereafter  entirely  assumes  the  character  of  a  carcinoma. 
Rokitanski  and  Dittrich  were  the  first  to  describe  this  condition, 
but  Hauser  ("Das  chronische  Magengeschwiir,"  Leipzig,  1883) 
gave  the  most  accurate  histological  description  of  it.  In  1891, 
¥i.o\\m2i\\n  {B eriin.  klin.  Wocliensclir.,  1 89 1,  5  and  6)  reported  14  cases, 
to  which,  up  to  the  present  time,  as  far  as  we  know,  about  14  more 
can  be  added  from  literature.  In  this  form  of  carcinoma  the  gas- 
tritis is,  at  the  beginning  at  least,  limited  to  the  immediate  neigh- 
borhood of  the  ulcer,  or  it  may  be  entirely  absent.  Accordingly,  the 
functional  disturbances  are  less,  and  secretion  may  be  normal,  or  we 
may  even  have  hyperch\'lia.  Very  late  in  the  course  of  this  t}'pe 
the  remainder  of  the  mucosa  may  suffer  from  cancerous  infiltration 
or  gastritis,  just  as  is  the  case  with  the  ordinary  gastric  carcinoma, 
and  then  the  functional  disturbances  become  more  pronounced.  The 
diagnosis  of  carcinomatous  ulcer  can  be  made  if  a  tumor  can  be 
recognized,  together  with  normal  or  excessive  secretion  of  HCl  and 
a  progressive  cachexia.  Of  course,  the  previous  histor}^  which 
gives  an  account  of  years  of  gastric  pain, — whereas  cancer  patients 
have,  as  a  rule,  when  they  present  themselves  not  suffered  so 
long, — is  a  valuable  factor  in  the  diagnosis.  If  vomiting  of  blood 
or  melena  occurs  in  the  clinical  history,  the  diagnosis  becomes 
probable,  but  it  is  difficult  to  distinguish  between  carcinomatous 
ulcer  and  the  tumor-like  induration  of  a  large  simple  ulcer.  It  is  also 
difficult  to  distinguish  the  carcinomatous  ulcer  from  hypertrophic 
stenosis  of  the  pylorus.  Sometimes  the  recognition  of  secondary 
metastases  in  the  liver,  or  other  signs  of  cancerous  dissemination, 
such  as  ascites  and  peritoneal  carcinosis,  ma}-  be  deciding  factors. 
In  one  of  our  cases  there  was  no  tumor  to  be  felt,  only  symptoms 
of  cachexia  and  of  gastric  ulcer.  For  literature,  see  Rosenheim, 
"  Zur  Kenntniss  des  mit  Krebs  complicirten  runden  ^lagen- 
geschwiirs,"  Zcitsclirift  f.  klin.  Alcdiziu,  Bd.  xvii,  S.  116;  also 
Boas  [ioc.  cit.),  second  edition,  1895,  pp.  188  and  189,  and  Hem- 
meter,  iWze^  York  Med.  Record,  vol.  52,  No.  ii,  September  11,  1897, 

P-  365- 

Perforations. — When  the  carcinoma  perforates  into  other  hollow 


526  MALIGNANT    TUMORS    OF    THE    STOMACH. 

organs,  or  exteriorly,  life  may  be  maintained  for  a  short  time,  but 
perforation  into  the  pleural  or  pericardial  cavities,  or  into  the  lungs, 
rapidly  leads  to  death.  Gastrocolic  fistulse  cause  very  rapid 
emaciation,  because  the  ingesta  pass  directly  into  the  colon,  in 
which  very  little  digestion  and  resorption  occur.  With  this  kind  of 
perforation,  portions  of  excrement  may  be  vomited.  Bronchitis, 
traumatic  pneumonia,  and  pericarditis  may  accompany  the  disease. 
Tuberculosis  may  be  combined  with  gastric  carcinoma. 

Diagnosis. — The  majority  of  authors  say  that  fragments  of  the 
cancer  rarely  occur  in  the  vomit  or  are  brought  up  in  the  tube. 
In  fact,  it  appears  that  the  finding  of  carcinomatous  particles  is 
considered  an  accident.  It  is  probable  that  this  occurrence  is  said 
to  be  so  rare,  not  because  these  fragments  do  not  occur  in  the 
vomit  or  wash-water,  but  because  they  are  not  methodically  and 
systematically  looked  for.  The  great  importance  of  an  early  diag- 
nosis of  carcinoma  justifies  the  clinician  in  going  to  some  trouble 
in  order  to  find  these  fragments.  We  are  in  the  habit  of  feeding 
all  suspected  cases  for  forty-eight  hours  by  the  rectum.  There- 
after, the  stomach  is  washed  out  with  normal  salt  solution  ;  for 
this  purpose  we  use  a  stomach-tube,  which,  though  quite  soft,  is 
provided  with  a  sharp  chisel-like  edge  around  the  lower  opening. 
This  tube  in  being  moved  about  in  the  stomach  is  much  more 
likely  to  dislodge  surface  particles  of  the  neoplasm  than  the  tubes 
ordinarily  used.  There  is  every  reason  why  we  should  intention- 
ally attempt  to  secure  cancer  particles  from  the  stomach  just  as 
they  are  secured  by  curetting  from  the  uterus.  We  have  been 
able,  in  this  manner,  to  find  particles  of  the  neoplasm  in  the  wash- 
water  after  it  has  been  permitted  to  settle  in  a  conical  glass  for 
about  six  hours,  or  after  the  solid  particles  were  brought  down  with 
the  centrifuge.  When  the  sediment  in  the  bottom  of  the  glass  is 
first  examined  by  a  low  power,  and  afterward  by  the  higher  power  of 
the  microscope,  cells  in  a  state  of  mitosis  can  frequently  be  found. 
Previous  to  the  rectal  feeding,  we  wash  out  the  stomach  thoroughly 
in  order  to  avoid  confounding  cancer  particles  with  particles  of 
meat,  etc.,  retained  with  the  ingesta.  If  this  method  is  systematic- 
ally followed,  we  believe  that  cancer  particles  will  be  more  frequently 
found;  nor  should  we  always  deny  the  existence  of  carcinoma 
when  we  find  no  fragment  giving  the  typical  histological  structure 
of  these  neoplasms,  as  described  under  their  pathology. 

Whenever  we  find   pieces   of   mucosa   in   which   the   glandular 


FRAGMENTS    SHOWING    MITOSIS.  527 

ducts  are  elongated  and  dilated,  and  the  cells  present  numerous 
karyokinetic  figures  and  forms  of  mitosis,  and  when  asymmetrical 
and  hypochromatic  forms  are  found,  the  possibility  of  the  exist- 
ence of  carcinoma  must  suggest  itself,  even  when  typical  carcinoma 
cells  are  absent;  particularly  when  the  interstitial  tissue  is 
considerably  broadened,  and  shows  much  small  round-cell  infiltra- 
tion in  addition  to  above  changes. 

Whenever  cancer  is  suspected  the  wash-water  should  be  obtained 
from  the  fasting  stomach  in  the  morning,  before  any  food  is  taken  ; 
preferably,  the  contents  should  be  drawn  by  the  expression  method 
without  dilution,  and  any  cellular  detritus  brought  down  by  the 
centrifuge.  In  speaking  of  Rieder's  pioneer  work  in  this  direc- 
tion, George  Dock  ("  Cancer  of  the  Stomach  in  Early  Life," 
Americmi  Journal  of  the  Medical  Sciences,  June,  1897,  p.  655)  ex- 
presses himself  as  follows :  "  It  was  therefore  a  matter  of  great  in- 
terest when  Rieder  {Deutsches  Archiv  fur  klin.  Med.,  Bd.  liv,  H.  6, 
p.  544)  reported  a  case  in  which  he  made  a  diagnosis  of  malignant 
disease  of  the  peritoneum  and  pleura  from  finding  numerous  cells 
in  the  exudates,  showing  indirect  nuclear  division."  The  patient 
was  a  woman  of  forty  years.  "  Section  showed  sarcoma  (car- 
cinoma?) of  the  peritoneum,  probably  secondary  to  malignant  dis- 
ease of  the  ovaries."  In  the  fluids  obtained  during  life,  cells  were 
found  which  were  remarkable  "  in  the  first  place,  on  account  of  the 
differences  in  size  and  shape  of  the  individual  cells.  Often  there 
were  indentations  and  constrictions,  sometimes  buddings.  In  many 
cells  there  were  one  or  many  vacuoles,  often  so  large  that  the 
nucleus  was  pushed  to  one  side,  sometimes  hardly  visible.  The 
nuclei  varied  in  size  and  number."  The  examination  of  the  stained 
cells  showed  large  numbers  of  cells  in  a  state  of  indirect  division, 
and  especially  cells  with  atypical  mitoses. 

"  The  most  remarkable  features  of  the  sediment  are  presented  by 
the  great  number  of  karyokinetic  figures.  These  are  especially 
common  in  cells  from  12  to  18  mm.  in  diameter.  The  protoplasm 
of  these  cells  is  usually  more  homogeneous  than  that  of  others. 
Vacuoles  sometimes  occur,  and  in  rare  cases  the  protoplasm  may 
be  very  much  degenerated.  Mitoses  are  so  numerous  that  every 
field  contains  one  or  more.  Often  two  to  five  can  be  seen  in  a 
small  field.  Various  stages  of  nuclear  and  cell  division  are  present. 
The  most  common  is  that  of  the  equatorial  plate.  The  spirem 
and  the  monaster  are  uncommon.     The  metaphase  is  not  so  easily 


528  MALIGNANT    TUMORS    OF    THE    STOMACH. 

recognizable,  partly  on  account  of  the  obscurity  of  many  of  the 
figures.     The  anaphase  is  common." 

Cells  containing  more  than  one  nucleus,  and  with  the  nuclei  in 
different  stages,  are  also  common.  In  these  cells  one  or  more  of  the 
nuclei  are  in  the  resting  stage,  and  one,  or  sometimes  more,  in  vari- 
ous stages  of  indirect  division  and  sometimes  showing  an  atypical 
figure. 

The  mitoses  found,  so  far  as  they  can  be  studied  by  the  chro- 
matin alone,  show  all  the  common  abnormalities.  Thus,  we  find 
hypo-  and  hyperchromatic  nuclei,  the  latter  being  rare.  Giant 
mitosis  may  be  represented  by  the  tripolar  figure.  Asymmetrical 
mitosis  is  not  easy  to  recognize  on  account  of  the  imperfect  preser- 
vation of  the  chromosomes  in  many  cases.  The  examples  of 
mitosis  in  multinuclear  cells  resemble  often  the  figures  given  by 
Krompecher  ("  Ueber  die  Mitose  mehrkerniger  Zellen,  und  die 
Beziehung  zwischen  Mitose  und  Amitose,"  ArcJi.  filr  path.  Anal., 
Bd.  cxLii,  p.  447). 

The  interesting  history  of  atypical  mitosis  can  only  be  touched 
on  here.  Eberth  {Arc/iiv  fur  path.  Anat.  wid  PhjsioL,  Bd.  lxvii) 
was  the  first  to  describe  division  into  four  parts,  but  his  statements 
were  at  first  discredited  by  Flemming  and  Strassburger.  Later, 
however,  Arnold  [ibid.,  Bd.  Lxxxiii)  found  multiple  karyokinesis 
in  carcinoma.  He  thought  the  process  might  result  in  polynuclear 
cells.  Since  then  a  great  deal  of  work  has  been  done  on  this  sub- 
ject, much  of  it  being  excited  by  the  ingenious  speculations  of 
Hansemann.  From  an  examination  of  the  work  done  so  far  it 
appears  that  atypical  mitoses  are  found  in  various  pathological 
conditions,  not  only  in  new  growths  like  cancer  and  sarcoma,  but 
also  in  benign  tumors  and  in  regenerations ;  in  short,  "  in  all  tis- 
sues of  strong  reproductive  activity  and  when  there  is  active 
mitosis  "  (Strobe).  They  are  also  found  in  tissues  irritated  by 
various  poisons,  such  as  quinin,  chloral,  nicotin,  etc.,  or  in  tissues 
exposed  to  high  temperature  (Galeotti).  In  cancer  all  observers 
find  them  in  great  richness  and  variety,  but  the  view  that  the  pres- 
ence of  even  a  large  number  of  pathological  mitoses  in  a  tissue 
justified  the  diagnosis  of  cancer  is  gradually  being  abandoned.  As 
the  literature  is  quoted  in  the  works  of  Hansemann  [Arch,  filr  path. 
Anat.,  Bd.  cxix,  p.  299,  Bd.  cxxiu,  p.  356,  Bd.  cxxix,  p.  436; 
"Studien  iiber  die  Specificitat  den  Altruismus  und  die  Anaplasis 
der  Zellen,"  Berlin,  1893),  Strobe  [Beitrdge  znr  path.  Anat.,  Bd.  xi. 


THE    EARLY    DIAGNOSIS    OF    GASTRIC    CANCER.  529 

xiv),  Cornil  {^Journal  de  I'Anat.  et  de  la  Physiol.  Norm,  et  Path., 
1891,  tome  xxvii,  p.  97),  and  Galeotti  [Beitrdge  ziir  path.  Anat.,  Bd. 
XIV,  xx),  it  is  not  necessary  to  give  a  complete  bibliography  here 
(George  Dock,  loc.  cit^. 

The  conclusion  is  justifiable  that  although  the  presence  of  a 
large  number  of  cells  in  stomach  contents  showing  mitosis  is  not 
pathognomonic  of  carcinoma,  nevertheless  it  is  very  significant,  and 
should  stimulate  further  clinical  investigation  toward  positive  dem- 
onstration of  existence  of  malignant  gastric  neoplasm. 

We  have  found  in  one  case,  four  weeks  before  the  tumor  at  the 
pylorus  was  palpable,  portions  of  gastric  mucosa,  in  which  the 
glandular  ducts  were  very  closely  packed,  containing  numerous 
leukocytes  and  showing  a  marked  atypical  appearance  of  the  gland- 
ular epithelia,  differing  from  the  normal  gland-cells  by  intense  pig- 
mentation of  the  nuclei  and  much  darker  staining  of  the  proto- 
plasm. Such  appearances  in  fragments  should  stimulate  further 
careful  and  frequent  examinations.  Sooner  or  later,  in  our  expe- 
rience, a  fragment  will  be  obtained  which  will  give  the  typical 
structure  of  carcinoma. 

Concerning  the  significance  of  the  Oppler-Boas  bacillus  we  have 
already  spoken  in  the  first  part  of  this  work.  We  can  confirm  the 
opinions  of  the  authors  quoted,  that  this  organism  is  a  very  impor- 
tant diagnostic  sign  in  this  disease.  We  have  thus  far  examined 
16  cases  of  gastric  carcinoma,  and  found  the  organism  present  in 
14.  Lactic  acid  is  a  valuable  sign  of  intragastric  fermentation, 
due  to  stagnation  from  dilatation  and  stenosis.  It  is  not  pathog- 
nomonic of  gastric  cancer,  because  it  may  not  be  present  in  excess 
even  in  cancer,  provided  the  gastric  peristalsis  is  unimpaired;  and 
again  it  may  be  present  when  the  pyloric  stenosis  is  due  to  a 
benign  obstruction.  However,  as  the  majority  of  gastric  cancers 
destroy  the  motility  and  cause  obstruction,  lactic  acid,  notwith- 
standing the  exceptions  reported  (William  S.  Thayer),  is  a  valuable 
diagnostic  sign.  (See  "  A  New  Test  for  Lactic  Acid  in  Gastric 
Contents,"  J.  P.  Arnold,  TJie  Joiirnal  of  the  American  Med.  Associa- 
tion, August  21,  1897.  This  is  a  modification  of  the  chlorid  of 
iron  test,  but  not  so  accurate  as  that  given  on  page  160.)  The 
value  of  an  early  diagnosis,  upon  which  the  success  of  any  possible 
operation  must  depend,  is  based  on:  (i)  the  recognition  of  tumors  ; 
(2)  the  finding  of  cancerous  particles  in  the  wash-water ;  (3)  demon- 
stration of  the  Oppler-Boas  bacillus  ;  (4)  the  excess  of  lactic  acid ; 
35 


530  MALIGNANT   TUMORS    OF    THE    STOMACH. 

(5)  the  absence  of  HCl  and  ferments  ;  (6)  the  occurrence  of  hema- 
temesis  and  melena ;  (7)  the  loss  of  motiHty  and  presence  of 
gastrectasia ;  (8)  the  general  symptomatology  and  anamnesis. 

After  a  short  resume  of  the  diagnostic  and  important  points  of 
the  various  types  of  gastric  carcinoma,  we  will  proceed  to  the 
details  of  the  medical  treatment.  For  the  surgical  treatment  we 
refer  to  the  section  devoted  to  that  subject. 

Resume  and  Synopsis  of  Main  Diagnostic  Factors  in  Car- 
cinoma Ventriculi — (Cancer  of  the  Stomach). — Gastric  cancer 
is  characterized  by  progressive  cachexia,  which  distinguishes  it 
from  all  other  chronic  affections  of  the  stomach.  It  is  not  suffi- 
cient for  diagnosis  and  therapy  to  diagnose  the  simple  presence  of 
cancer,  since  these  neoplasms  vary  so  greatly  according  to  their 
location  at  the  cardia,  the  curvatures,  and  the  pylorus,  and  in  so 
many  important  symptomatic  and  diagnostic  points  that  they  com- 
pel separate  consideration.  It  is  expedient  to  consider  these 
malignant  tumors  under  three  headings,  viz. : 

(i)  Carcinoma  of  the  cardia,  (2)  of  the  body  of  the  stomach,  i.  e., 
the  curvatures  and  the  fundus  and  walls,  (3)  of  the  pylorus. 

Carcinoma  of  the  Cardia. — Signs  and  Symptoms. — Complaints 
of  an  uncomfortable  feeling  of  a  foreign  body  and  of  pressure 
above  the  gastric  region,  particularly  after  the  ingestion  of  food. 
Sensations  of  pain  are  not  contemporaneous  with  swallowing  of 
food,  but  occur  independently.  On  ingestion  of  food  a  sensation 
as  if  the  same  becomes  clogged,  or  is  caught  before  it  reaches  the 
stomach  ;  patients  imagine  that  copious  draughts  of  water  give 
relief,  most  likely  because  this  can  pass  through  the  stenosis 
caused  by  the  neoplasm.  Another  important  symptom  is  vomit- 
ing, which  is  not  actual  gastric  vomit,  but  the  retching  up  of  mucus 
and  a  few  food  particles.  The  cause  of  these  regurgitations  of  masses 
of  mucus  is  the  formation  of  a  large  dilatation  of  the  esophagus 
above  the  stenotic  carcinoma  of  the  cardia.  In  this  esophageal 
diverticulum  or  dilatation  the  food  is  caught,  retained,  putrefies, 
and  is  eventually  vomited  up  again.  There  is  also  a  septic  catarrhal 
esophagitis  present  at  this  place.  Liquid  or  semi-liquid  substances 
may  for  a  long  time  be  able  to  pass,  while  relatively  solid  sub- 
stances give  rise  to  the  difficulties  stated.  Later  on,  as  the 
stenosis  increases,  liquids  can  not  pass  either,  and  loss  of  appetite 
and  strength  goes  on  uninterruptedly. 

If  an  obstacle  to  the  passage  of  the  sound  can  be   ascertained  at 


DIAGNOSIS    OF    CARCINOMA    OF    THE    CARDIA.  53  I 

the  entrance  to  the  stomach  in  a  person  over  thirty  years  of  age, 
the  diagnosis  of  cancer  of  the  cardia  becomes  certain.  In  all 
such  suspected  cases  only  a  soft  elastic  tube  should  be  used 
for  explorative  sounding.  In  two  cases  in  private  practice  we 
were  enabled  to  establish  the  diagnosis  by  microscopical  exami- 
nation of  small  portions  of  the  carcinoma  that  were  brought 
up  with  the  sound.  These  neoplastic  fragments  are  occasionally 
found  in  the  eye  of  a  lower  opening  of  the  sound,  and  they 
constitute  a  definite  criterion.  In  one  of  the  above  cases  the  diag- 
nosis was  confirmed  by  Dr.  M.  Einhorn,  and  in  the  other  by  autopsy. 
In  addition  to  the  sounding  and  the  cancerous  fragments,  the  fol- 
lowing signs  are  of  diagnostic  importance  : 

1.  Percussion  of  the  region  over  xiphoid  cartilage  is  very  painful. 

2.  On  the  sound,  blood  will  frequently  be  found  mixed  with  the 
extremely  fetid  mucus,  and  at  times  nests  of  cancer  cells. 

3.  On  placing  a  stethoscope  over  the  epigastrium,  normally  two 
deglutition  sounds  can  be  heard.  One  is  synchronous  with  the 
beginning  of  the  act  of  swallowing,  and  the  other  is  heard  from 
seven  to  twelve  seconds  later.  Now,  in  carcinoma  of  the  cardia 
the  second  deglutition  sound,  which  signifies  the  entrance  of  liquid 
into  the  stomach,  may  be  much  delayed  or  absent  entirely;  this 
sign  is  of  importance/^;' i'^. 

4.  Supraclavicular  swelling  of  the  lymph-glands,  if  palpable, 
supports  the  diagnosis  also. 

5.  Lauenstein  asserts  that  there  is  a  systolic  murmur  audible  in 
the  epigastrium,  due  to  pressure  of  the  tumor  upon  the  aorta. 
According  to  Boas  this  is  an  inconstant  sign. 

Duration  of  the  disease  is  six  to  nine  months  after  the  first 
symptoms  are  manifested;  death  occurs  as  a  result  of  gradual 
exhaustion,  marasmus,  aspiration  pneumonia,  secondary  carcino- 
mata  in  the  liver  and  other  organs,  and  intercurrent  hemorrhages. 

Differential  diagnosis  from  chronic  gastritis  is  difficult  in  the 
beginning  of  the  cancer,  as  in  both  the  presence  or  absence 
of  hydrochloric  acid  is  no  criterion  ;  but  as  the  cancer  progresses 
the  sound  will  settle  the  doubt  in  locating  the  stenosis.  From 
esophageal  ulcer  the  cardia  carcinoma  is  differentiated  by  the  fact 
that  pain  is  immediately  associated  with  deglutition  of  food,  by  the 
age  of  patient  (see  tables  of  ages  at  which  ulcer  and  cancer  are 
most  frequent),  by  the  hematemesis  and  the  bloody  stools  of  ulcer. 
Ulcer  of  the  esophagus  is  extremely  rare  in  comparison  to  cancer. 


532  MALIGNANT    TUMORS    OF    THE    STOMACH. 

From  diverticulum  the  cardia  carcinoma  is  differentiated  by  the 
following  facts  :  Diverticulum  is  frequent  in  the  upper  third,  rare 
in  the  lower  third,  of  the  esophagus.  The  permeability  of  the 
gullet  will  be  more  variable  than  in  cancer,  because  the  sound  will 
often  skip  the  diverticulum.  In  the  latter  there  will  rarely  be  pain, 
and  the  marasmus  will  not  be  so  progressive  and  rapid.  From 
cardiospasm,  or  cramp  of  the  cardia,  the  carcinoma  is  differenti- 
ated by  the  occasional  free  passage  of  the  thickest  tubes  in  the 
neurosis,  which  occurs  almost  exclusively  in  neurasthenics.  Nutri- 
tion is  not  so  much  damaged  as  in  cancer. 

If  tuberculosis  or  syphilis  be  present,  one  must  think  of  the 
possibility  of  the  neoplasm  being  caused  by  these  diseases. 

Treatment  of  Cardia  Carcinoma. — So  long  as  there  is  no  cure 
possible,  this  must  be  palliative.  During  the  time  that  deglutition 
still  brings  liquid  food  into  the  stomach  the  sufferer  must  be  care- 
fully fed  on  highly  nutritious  liquid  diet — liquid  eggs  and  wine,  as 
described  in  the  diet  of  gastritis,  beef-tea,  soups  of  fluid  potato  or 
pea  puree  in  bouillon,  Leube-Rosenthal  beef  solution,  von  Mehr- 
ing's  Kraft  chocolate,  egg-nog.  When  pain  was  great  we  have 
found  that  chloral  hydrate,  grs.  xv,  t.  i.  d.,  not  only  relieved  it  but 
acted  as  a  local  disinfectant  in  the  diverticulum  above  the  stenosis. 
Boas  recommends  iodid  of  potassium  in  doses  of  15  gm.  three 
times  daily  as  aiding  in  keeping  the  esophagus  from  closing  up  as 
soon  as  it  would  otherwise.  Arsenic  is  said  to  effect  the  same  pro- 
longed permeability. 

In  one  case  we  succeeded  in  keeping  the  esophagus  open  for  six 
months  by  intubating  with  an  inelastic  tube  four  inches  long  and 
as  wide  as  an  ordinary  Ewald  tube.  The  tube  was  removed  every 
ten  days  and  replaced.  Patient  lost  no  weight  in  those  six  months, 
but  even  gained.  Death  was  caused  by  aspiration  pneumonia, 
during  a  period  in  which  the  tube  was  left  out  in  order  to  rest  the 
esophagus  from  the  stout  cord  by  which  the  tube  was  connected 
with  the  mouth,  and  which  was  usually  tied  around  the  patient's 
neck. 

When  deglutition  is  impossible,  the  only  thing  left  to  be  done  is 
gastrostomy.  If  the  patient  can  be  persuaded  to  undergo  this 
operation,  it  should  be  done  before  marasmus  proceeds  too  far,  as  it 
then  prolongs  life  and  the  shock  of  the  operation  is  better  borne. 

This  operation  consists  in  making  an  opening  into  the  stomach 
for  the  purpose  of  feeding  the  patient  by  passing  food  directly  into 


SIGNS    IN    CARCINOMA    OF    THE    BODY    OF    STOMACH,  533 

the  organ.  F.  Kaiser  (in  Czerny,  Beitr.  z.  operativ  Chiriirg^  collected 
31  gastrostomies  ;  of  these,  28  died  of  the  immediate  results  of  the 
operation.  Zesas  [Arcliivf.  klin.  Chirurg.,  Bd.  xxxii,  S.  188)  reported 
131  cases  from  literature,  mostly  esophageal  cancers,  which  in  their 
stenosing  effects  are  identical  with  those  of  the  cardia.  Among 
these  only  19.5  per  cent,  recovered  sufficiently  from  the  operation 
to  call  this  a  success.  A  cure  is  out  of  the  question ;  gastrostomy 
a  palliative  measure  only.     (See  pp.  356,  357.) 

Carcinoma  of  the  Body  of  the  Stomach. —  {^Pylorus  Cancer  of 
the  Fundus,  Ante7'ior  or  Posterior  Walls,  the  Curvatures  and  Pylorus^ 

Subjective  Signs. —  i.  Sudden  abrupt  beginning  of  the  disease, 
striking  an  apparently  healthy  organ. 

2.  Loss  of  appetite  in  90  per  cent,  of  cases. 

3.  Aversion  to  meat. 

4.  In  stenosing  pyloric  cancer  there  is  much  thirst. 

5.  Frequent  eructations,  which,  when  there  is  dilatation,  can  be 
very  offensive. 

6.  Pressure  in  the  beginning,  pain  later  on. 

7.  There  is  frequent  vomiting,  which  is  more  copious  in  pyloric 
cancers  because  of  the  accumulations  from  the  dilatation. 

Frequently  the  vomit  has  a  coffee-ground  appearance,  and  the 
hemin  test  (referred  to  in  part  i)  proves  the  presence  of  blood. 
The  state  of  the  bowels  is  variable.  The  vomit  contains,  as  a  rule, 
no  hydrochloric  acid,  but  excess  of  lactic  acid  and  Oppler-Boas 
bacilli. 

Objective  Signs. — On  inspection,  palpation,  and  percussion  a 
tumor  can  be  made  out  in  at  least  50  per  cent,  of  the  cases. 

Tumors  of  the  pylorus  do  not  move  with  the  respiratory  move- 
ments unless  attached  to  the  liver  ;  tumors  of  the  curvatures  gen- 
erally show  distinct  respiratory  movements. 

Examination  of  Stomach  Contents. — The  results  will  be  character- 
istic in  most  cases  and  evince — 

1.  Grave  interference  with  the  motility. 

2.  Suppression  of  secretion. 

3.  Products  of  stagnation  dependent  upon  these. 

The  disturbances  of  peristalsis  are  due  most  likely  to  a  direct 
invasion  of  the  muscularis  by  cancerous  proliferation.  The  simplest 
way  of  testing  the  motor  disturbance  is  to  cleanse  the  stomach 
thoroughly  by  lavage  in  the  evening,  giving  a  test-supper  thereafter 
and  examining  the  following  morning,  when,  normally,  the  stomach 


534  MALIGNANT    TUMORS    OF    THE    STOMACH. 

should  be  empty  ;  but  in  carcinoma  much  food  and  mucus,  with 
absence  of  hydrochloric  acid  and  presence  of  lactic  acid,  is  found 
in  88  per  cent,  of  the  cases  in  our  experience.  In  carcinomata  that 
have  arisen  from  old  ulcers  there  is  claimed  to  be  a  secretion  of 
hydrochloric  acid  until  the  last  stages  of  the  disease.  This  asser- 
tion of  Rosenheim's  is  not  always  correct,  as  we  have  shown  twice 
this  winter  at  our  clinic.  If  the  glandular  layer  is  invaded,  secretion 
must  cease,  no  matter  whether  the  carcinoma  arose  from  an  ulcer 
or  not.  Lactic  acid  is  tested  for  by  Uffelmann's  reaction ;  in  carci- 
noma there  is  an  excess  in  from  86  to  90  per  cent,  of  the  cases. 
Demonstration  of  the  long,  base-ball-bat-shaped  Oppler-Boas 
bacillus  is,  according  to  Kaufman,  Schlesinger,  and  Riegel,  a  very 
important  sign.  There  should  always  be  a  careful  lookout  for 
histological  evidences,  such  as  bits  of  the  growth  in  the  wash-water 
and  vomit;  this  clinches  the  diagnosis. 

Secondary  symptoms  are  anemia,  cachexia,  and  edema  of  the 
ankles  in  15  to  20  per  cent,  of  the  cases.  The  urine  contains 
excess  of  nitrogen  excretion,  indican,  and  peptone.  Latent  cancers 
may  occur;  they  are  very  rarely  observed,  however,  at  the 
autopsy. 

Ulcus  Carcinomatosiini. — The  diagnosis  is  made  from  a  history  of 
ulcer,  with  years  of  gastric  pain,  not  a  sudden  and  abrupt  beginning, 
and  the  presence  of  hydrochloric  acid,  even  hyperacidity.  A 
previous  history  of  hematemesis  and  blood  in  the  stools  points 
to  origin  of  the  carcinoma  from  ulcer.  Simple  uncomplicated  ulcer 
may  cause  a  tumor-like  thickening,  simulating  cancer  ;  here  the 
analysis  of  gastric  contents  may  even  show  excess  of  lactic  acid, 
owing  to  motor  insufficiency  and  cicatricial  stenosis,  and  the  diag- 
nosis then  becomes  difficult,  as  is  also  the  differential  diagnosis  of 
ulcus  carcinomatosum  from  simple  hypertrophic  stenosis  of  the 
pylorus.  Fortunately  such  states  without  any  other  important  signs 
are  rare. 

Treatment. — There  is  no  successful  medicinal  treatment  for  this 
disease.  Life  may  be  prolonged  by  a  suitable  diet,  as  nutritious  as 
possible  and  adapted  to  the  individual  conditions.  A  highly  nutri- 
tious proteid,  carbohydrate,  and  fatty  diet  should  not  be  interdicted  so 
long  as  the  motility  is  good  and  the  patient's  strength  can  be  upheld 
by  intestinal  digestion.  Where  there  is  stagnation  owing  to  pyloric 
obstruction,  the  carbohydrates  and  fats  must  be  diminished.  The 
best  tonic  for  the  stomach  is  daily  lavage,  even  where  there  is  not 


TREATxMENT    OF    GASTRIC    CANCER.  535 

much  stagnation  ;  but  where  the  latter  is  marked  and  accompanied 
by  fermentation,  antiseptics  may  advantageously  be  added,  such  as 
boracic  acid,  20  to  30  :  looo  H2O  ;  salicylic  acid,  3  :  1000  H2O  ; 
sodium  benzoate,  10  to  30  :  1000  HgO  ;  resorcin,  10  to  30  :  1000 
H2O;  thymol,  5  :  lOOO  H2O ;  lysol,  I  to  2  :  lOOoHjO;  hydro- 
chloric acid,  4  to  5  :  1000  H2O.  It  is  always  well  to  get  the 
stomach  clean  by  simply  using  warm  salt  solution,  and  to  finish  the 
lavage  by  a  last  irrigation  with  one  of  the  disinfectants,  of  which 
we  prefer  hydrochloric  acid. 

A  tonic  which  has  been  serviceable  in  our  experience  and  which 
will  arouse  appetite  and  promote  digestion  in  the  invaded  organ,  if 
this  is  at  all  possible,  is  the  following: 

Ht .      Extract,  condurango, 45.0  c.c.  f^^ij 

Strychnin   sulphatis, 0.021  c.c.        gr-  j^ 

Hydrochloric  acid,  dil., 12. o  c.c.  f^iij 

Elixir  gentianas,       .    .    .  q.  s.  .    .    .  180.0  c.c.  f^vj.  M. 

SiG. — Take  f^ss  in  f^ij  aquae,  after  meals,  through  a  tube. 

When  there  is  much  anemia,  the  following  formula  has  our 
preference  in  this  disease  as  well  as  in  ulcer  : 

R.     Solution  of  iron  and  manganese  (Parke,  Davis  &  Co.),  f^vj 

Liquor  potassi  arsenit, TTLxlviij.  M. 

SiG. — f^ss,  t.i.d. 

Constipation  is  best  met  by  large  colon  irrigations  or  with  the 
fluid  extract  or  active  syrup  of  cascara  sagrada.    (Clinton.) 

Diarrhea  must  be  met  by  salol,  bismuth  salicylate,  or  benzo- 
naphthol.     Opiates  are  not  advisable  for  this  symptom. 

For  pain,  hot  external  cataplasms  and  20  to  30  drops  of  compound 
spirit  of  ether  should  be  first  tried.  If  severe,  codein,  gr.  y^,  extract. 
Belladonnae.gr.  ^,in  fsj  of  peppermint  water,  generally  relieves  it,  and 
may  be  repeated  if  requisite.  The  pain  is  rarely  so  intense  as  to 
require  hypodermic  injections  of  morphin.  Lavage  systematically 
and  scientifically  employed  seems  to  prevent  pain ;  it  certainly 
prolongs  life  and  sometimes  apparently  works  wonders  for  these 
patients. 

For  the  diet  in  gastric  carcinoma  we  refer  to  the  chapter  on 
Dietetics,  page  231. 

Fifty  gm.  of  rich  milk  or  a  glass  of  tokay,  a  few  crackers,  and 
chocolate  are  permissible  foods,  also  young  pigeon,  partridge,  and 
prairie  chicken.     If  the  motility  is  good,  one  must  not  be  too  severe 


536  MALIGNANT  TUMORS  OF  THE  STOMACH. 

on  the  patient's  desire  for  food  ;  many  cases  can  live  and  gain 
strength  on  an  ordinary  nourishing  diet  when  it  is  not  retained 
too  long  in  the  stomach  ;  under  these  circumstances  mutton  chops 
and  broiled  beefsteak,  finely  minced,  may  be  allowed. 

Surgical  Treatment. — As  already  mentioned,  gastrostomy  is  a 
palliative  operation  for  malignant  tumor  of  the  cardia  and  esopha- 
gus, to  permit  of  direct  introduction  of  food  by  establishing  an 
opening  between  the  stomach  and  the  abdominal  wall.  In  carcinoma 
of  the  pylorus  another  palliative  operation  is  practised,  where  it  is 
impossible  or  inexpedient  to  remove  the  growth,  under  the  name 
of  gastro-enterostomy.  This  consists  in  the  establishment  of  a  new 
communication  between  the  stomach  and  the  small  intestine,  thus 
allowing  the  chyme  to  reach  the  intestines  without  passing  the 
pylorus. 

The  radical  operations  are  resections  of  the  pylorus  and  excision 
of  the  tumor,  no  matter  where  it  may  be  situated  in  the  stomach* 
These  operations  are  contraindicated  if  metastases  are  detectable 
in  other  organs,  by  the  presence  of  great  anemia  or  cachexia, 
by  the  large  size  of  the  tumor,  or  if  there  are  adhesions  to  other 
organs.  The  detailed  descriptions  of  these  operations  belong  to 
text-books  on  abdominal  surgery  : 

See  "  Surgery  of  the  Alimentary  Canal,"  by  A.  Ernest  Maylard;  P.  Blakis- 
ton,  Son  &  Co.,  Philadelphia,  1896. 

"  Abdominal  Surgery,"  by  J.  Greig  Smith,  published  by  P.  Blakiston,  Son  & 
Co.,  Philadelphia,  1896. 

"  Surgery  by  American  Authors,"  by  Roswell  Park,  vol.  11,  chap,  8,  pub- 
lished by  Lea  Brothers,  Philadelphia. 

"  System  of  Surgery,"  by  Fred.  S.  Dennis,  vol.  iv,  p.  217. 

"  Abdominal  Surgery,"  by  M.  H.  Richardson  and  Farrar  Cobb. 

"  A  Text-book  of  Abdominal  Surgery,"  by  Skene  Keith  and  G.  S.  Keith. 

Fred'k  Treve's  "  Manual  of  Operat.  Surgery,"  vol.  II,  p.  405. 

Franz  Koenig,  "  Lehrbuch  d.  speciel.  Chirurg.,"  Bd.  11,  S.  281. 

Penzoldt  and  Stintzing's  "  Handbuch  d.  speciel.  Therapie,"  vol.  iv,  p.  444. 
("  The  Operative  Treatment  of  Gastric  Disorders,"  by  Prof,  von  Heinecke. 
Erlangen.) 

Diagnostic  Resume  and  Treatment. — Cancer  of  the  stomach, 
which  in  by  far  the  larger  number  of  cases  is  primary,  is,  like  all 
cancers,  a  disease  of  advanced  age,  so  that  about  75  per  cent,  of  all 
the  cases  occur  between  the  ages  of  forty  and  seventy.  According  to 
Haberlin,  the  number  of  fatal  cases  a  year  in  looo  people  is,  in 
the  forties,   o.i  ;  in   the  fifties,  0.46;    in   the  sixties,   1.35;    in  the 


RESUME    OF    DIAGNOSIS.  537 

seventies,  2.67;  in  the  eighties,  3.31.  But  one  must  not  rely  too 
much  upon  age,  since,  according  to  statistics,  ten  per  cent,  of 
all  cases  of  carcinoma  of  the  stomach  come  in  the  thirties  and 
about  two  per  cent,  in  the  twenties. 

A  further  factor  in  the  development  of  carcinoma  of  the  stomach 
is  heredity,  either  cancer  in  general,  or  cancer  of  the  stomach  in 
particular,  may  often  be  proved  in  the  ascendance.  Figures  are  of 
little  value  in  expressing  the  relation. 

Of  the  other  favoring  causes,  only  ulcer  of  the  stomach  has 
been  determined  with  certainty.  Hauser  has  proved  directly  and 
histologically  the  transition  from  ulcer  to  cancer.  The  statistics 
of  Haberlin  show  that  in  more  than  seven  per  cent,  of  the  cases 
carcinoma  appeared  after  ulcer.  Among  the  etiological  factors 
we  also  find  recorded  traumatism,  corrosions,  and  infections.  They 
are  probably  only  collateral  accompaniments,  or  coincidents. 

Concerning  the  seat  of  gastric  carcinoma,  we  have  already  given 
the  statistics  of  Welch,  Brinton,  Haberlin,  and  others,  under  the 
pathology. 

Occurrence  and  Detection. — With  the  exception  of  the  cases  that 
arise  from  ulcer,  cancer  of  the  stomach,  as  a  rule,  develops  gradually. 
Among  the  phenomena  are  symptoms  of  more  or  less  severe  dys- 
pepsia, gradually  ranging  to  the  most  decided  ones  of  chronic 
gastritis,  which,  almost  without  exception,  accompany  every  car- 
cinoma of  the  stomach.  Therein  lies  a  great  hindrance  to  timely 
detection.  If,  however, — and  this  especially  in  older  individuals, — 
the  symptoms  of  chronic  gastritis  appear  without  any  distinct  cause, 
and  in  a  stomach  previously  entirely  sound,  and  get  worse  con- 
stantly, even  with  a  mild  diet,  and  are  increased  by  pains  and 
vomiting  even  before  food  is  taken  (with  a  jejune  stomach),  so  that 
in  a  few  weeks  rapid  emaciation,  with  an  extraordinary  sallow  com- 
plexion, become  pronounced  features,  carcinoma  of  the  stomach 
may  be  suspected. 

What  are  the  characteristic  and  most  important  diagnostic  signs 
of  gastric  carcinoma  ?  Examination  with  the  stomach-tube  is  to 
be  made,  and  the  reaction  for  free  acid  in  the  contents  of  the 
stomach  which  have  been  brought  up  one  hour  after  the  trial 
breakfast  is  to  be  tried.  In  any  case,  the  treatment  with  lavage  is 
to  be  instituted,  and  with  it  the  most  frequent  repetition  of  the  test 
for  free  acid.     In  this  connection  it  is  well  to  make  examination  of 


538  MALIGNANT    TUMORS    OF    THE    STOMACH. 

the  juices  after  several  trial  meals,  and  eventually  with  means  in- 
citing to  the  secretion  of  acids  (orexin),  but,  of  course,  always  at  a 
time  when,  under  normal  circumstances,  free  acid  ought  to  be 
present.  Protracted  absence  of  free  hydrochloric  acid, even  though 
it  may  occur  in  other  diseases  of  the  stomach,  speaks,  in  the 
method  of  procedure  indicated,  with  great  probability  for  cancer, 
since  in  more  than  90  per  cent,  of  the  cases  HCl  was  found  absent. 
Frequent  presence  of  hydrochloric  acid  argues  against  cancer. 
Repeated  examination  with  the  tube  brings  us  other  signs  of 
carcinoma,  which,  by  other  observations,  are  not, — or  at  any 
rate  not  so  easily, — obtained.  Occasionally  a  particle  of  the 
cancer  is  found  in  the  vomited  masses,  and  the  diagnosis  is  made 
sure.  This  may  happen  more  easily  with  lavage  in  the  wash- 
water  from  carcinoma  of  the  cardia,  when  it  also  may  be  found 
in  the  eye  of  the  tube.  During  methodical  lavage  the  coffee- 
ground  vomit  is  seen  earlier  and  more  frequently  than  if  we 
depend  upon  the  vomiting,  and,  further,  in  the  latter  case  it  is  often 
poured  away  before  the  physician  gets  a  chance  to  examine  it.  In 
case  of  carcinoma  one  does  not  need  to  fear  hemorrhage  in 
probing,  provided  it  is  done  carefully.  Finally,  one  may  also  use 
the  contents  of  the  stomach  obtained  with  the  tube  for  the  quanti- 
tative and  qualitative  determination  of  lactic  acid.  (See  page  160.) 
An  approximately  simple  calculation  for  this  purpose  has  been 
recently  published  by  H.  Strauss,  of  Riegel's  Klinik  {Berlin,  klin. 
WocJienschr.,  1895,  No.  37).  The  abnormal  presence  of  lactic 
acid,  according  to  Boas  and  others,  occurs  in  70  per  cent,  of  the 
cases  of  cancer.  It  is  true  that  it  has  also  been  shown  by  him 
and  other  authors  to  exist  with  gastritis  and  hypertrophic 
benign  stenosis  of  the  pylorus,  which  somewhat  diminishes  its 
value.  But  still,  as  it  appears  at  present,  in  connection  with 
other  signs  it  is  valuable  for  an  early  diagnosis,  even  though 
its  absence  does  not  argue  against  carcinoma  and  was  especially 
observed  in  carcinomatous  ulcer.  It  will  therefore  be  possible  in 
most  cases  to  fix  the  diagnosis  with  a  great  degree  of  probability, 
even  before  a  tumor  is  palpable,  when  elderly  persons  previously 
sound  grow  rapidly  worse  in  spite  of  suitable  treatment  and  when 
cachectic  symptoms  appear  quickly,  when  the  absence  of  free 
hydrochloric  acid  continues,  or  when  there  is  vomiting  of  coffee- 
ground   masses.     Since  ordinarily  the  tumor  can  only  be  felt  when 


THERAPEUTIC    RESUME.  539 

the  cancer  has  reached  a  certain  size  and  lies  in  an  especially 
favorable  position,  the  diagnosis  by  recognition  of  a  tumor  is  gener- 
ally no  longer  an  early  diagnosis.  The  examination  in  chloroform 
nardosis  must  be  brought  in  at  a  comparatively  early  date  to 
facilitate  palpation,  and  with  a  sufficient  degree  of  insensibility  it 
will  indeed  very  much  facilitate  the  detection.  Distention  with 
air  through  the  stomach-tube,  renders  a  tumor  at  the  front  wall  or 
at  the  pylorus  more  distinctly  recognizable,  and  gives  information 
concerning  the  size  of  the  stomach.  Distention  of  the  intestine  in 
narcosis  by  means  of  air  is  also  brought  in  as  an  aid  to  the  diag- 
nosis. If  it  is  not  possible  to  feel  a  tumor,  and  if,  in  spite  of  this, 
one  is  convinced  that  a  neoplasm  does  exist,  one  should  propose  an 
exploratory  incision,  with  eventual  further  operative  procedures  if 
the  prospects -Warrant  immediate  good  results.  If  carcinoma  should 
follow  apparently  in  the  course  of  gastritis  or  ulcer,  the  diagnosis 
becomes  more  difficult  than  if  it  is  developed  in  an  apparently 
healthy  stomach,  for  then  the  symptomatology,  the  state  of  the 
secretions,  and  the  proof  of  the  presence  of  lactic  acid  or  hemor- 
rhage, are  of  much  less  value.  Then  the  diagnosis  requires  the 
greatest  circumspection.  Since  the  detailed  description  of  all  the 
possibilities  does  not  suit  the  compass  of  the  work,  we  will  here 
only  refer  again  to  the  fact  that,  with  rapidly  increasing  emacia- 
tion of  the  patients,  the  physician  must  not  rest  until  he  has 
found  the  causes  in  a  carcinoma,  or  in  another  factor,  such  as 
stenosis  of  the  pylorus.  In  cases  in  which  the  carcinoma 
causes  no  symptoms,  or  only  very  indefinite  ones  as  regards 
the  stomach  (for  instance,  in  the  case  of  people  advanced  in  age), 
the  diagnosis  is,  of  course,  impossible  and  treatment  not  so  impor- 
tant. If  there  is  a  palpable  tumor  in  the  region  of  the  stomach,  we 
have  the  problem  of  determining  that  the  same  is  really  a  new 
formation  belonging  to  the  stomach.  From  the  therapeutic  stand- 
point, one  is  to  avoid  confounding  it  with  tumors  which  either 
need  not  be  or  can  not  be  operated.  Among  the  former  are 
to  be  mentioned  the  normal  head  of  the  pancreas,  which  with 
severe  emaciation  might  be  mistaken  for  a  carcinoma;  lymphatic 
glands,  which  are  felt  as  small  smooth  nodules  alongside  of  the 
spinal  column  and  may  be  quite  harmless  (Leube) ;  tumor  of  the 
spleen,  which  can  not  be  grasped  from  above  ;  movable  kidney, 
which  is  smooth  and  which  gives  the  kidney  shape.  Of  the  non- 
operable  tumors,  or  only  exceptionally  operable,  we  should  exclude 


540  MALIGNANT    TUMORS    OF    THE    STOMACH. 

cancer  of  the  liver,  which,  without  the  characteristic  gastric  symp- 
toms of  the  stomach,  causes  the  Hver  to  appear  enlarged  and  much 
distended,  or  causes  nodules  to  appear  on  the  palpable  lower  edge 
(see  the  extension  of  the  cancer  from  the  stomach  to  the  liver). 
Gall-bladder  and  omental  carcinomas  are  chiefly  to  be  excluded  from 
diagnosis  by  the  absence  of  the  conspicuous  stomach  symptoms, 
and  the  latter  by  the  want  of  respiratory  movability  and  by  the 
presence,  generally,  of  ascites.  Carcinoma  of  the  mesenteric  glands 
is,  under  some  circumstances,  not  to  be  distinguished  from  that  of 
the  stomach,  as  Penzoldt  recently  observed  in  a  case  which  had,  in 
addition,  violent  hemorrhages  and  stomach  symptoms.  The  differ- 
ential diagnostic  points  from  tumors  of  the  duodenum,  colon,  and 
neighboring  organs  have  already  been  considered  (pp.  521-523). 

DIET  FOR  GASTRIC  CARCINOMA  {^Rosenheim). 

8  A.  M. — One  cup  of  tea  with  milk  or  a  farinaceous  soup,  eventually  with  a 
little  wheat  bread. 

10  A.  M. — Toast,  sardelles,  caviar,  perhaps  also  oysters,  with  good  red  wine, 
sherry,  or  Madeira. 

I  P.  M. — Bouillon  or  soup  (flour,  rice,  sugar,  and  tapioca  soups),  eventually 
with  addition  of  peptone,  or  Leube-Rosenthal's  meat  solution.  White 
meat  or  game,  or  beefsteak  from  finely  scraped  beef,  or  jellies  with  gravy, 
or  calves-feet.  Vegetables.  Potato  puree,  finely  chopped  spinach,  well 
cooked  asparagus. 

Stews  :  Stewed  apples,  pears,  prunes  (without  hulls). 
Drinks  :  Red  wine,  water  with  cognac. 

4  P.  M. — Meat  peptone,  chocolate  or  cocoa  with  cakes. 

7  p.  M. — Bouillon  and  soup  from  leguminous  flour. 

For  further  diet  for  gastric  carcinoma  see  p.  231. 

Treatment  of  Loss  of  Appetite. — Of  the  so-called  stomachic 
remedies  condurangorinda  enjoys  a  great  reputation.  We  prefer 
the  officinal  fluid  extract  of  condurango.  The  other  stomachics 
and  bitter  tonics  used  are  the  tinctures  of  Colombo,  gentian, 
cinchona,  etc.,  likewise  hydrochloric  acid,  which,  however,  does  not 
always  agree  with  the  patient.  Orexin  generally  has  no  effect, 
but  an  attempt  with  0.2  to  0.3  gm.  of  orexin  basicum  should  be 
made.  Also,  lavages  of  the  stomach  with  decoctions  of  hops  and 
quassia  wood,  according  to  Kussmaul  and  Fleiner,  may  be  used 
with  advantage.  Washing  the  stomach  remains  the  best  means 
for  exciting  the  appetite. 

Treatment    of     Vomiting. — Against    vomiting  we    recommend : 


TREATMENT    OF    INDIVIDUAL    SYMPTOMS.  54I 

small  quantities  of  ice,  ice-cold  water  containing  carbonic  acid  or 
champagne,  a  few  drops  of  chloroform,  tincture  of  iodin,  creasote, 
morphin  subcutaneously  or  as  a  suppository,  cold  bandages  on 
the  epigastrium.  If  it  is  a  consequence  of  stagnation  of  foods  in 
the  stomach,  lavage  is  the  most  efficacious  treatment.  If  the 
vomited  matter  has  a  foul  smell,  and  foul  belching  is  present,  one 
may  add  thymol  (0.5  per  cent.),  boric  acid  (two  to  three  per  cent.), 
salicylic  acid,  resorcin,  chloroform  (0.5  per  cent.),  to  the  wash-water. 
The  treatment  of  liemorrJiages  is  the  same  as  for  gastric  ulcer. 

Treatment  of  the  Pain. — Steam  vapor,  bandages,  and  poultices, 
hot  cloths  or  plates  have  only  a  temporary  success.  If  the  pains 
are  very  violent,  one  can  not  avoid  the  subcutaneous  injection  of 
morphin,  but  care  must  be  exercised  on  account  of  starting  the 
morphin  habit.     (See  p.  535.) 

Treatment  of  Constipation. — This  very  frequent  and  troublesome 
symptom  must  be  eliminated,  if  possible,  by  large  colon  irrigations 
(one  liter),  by  injections  of  water  with  the  addition  of  soap,  tur- 
pentine, castor  oil,  etc.,  which  increase  their  effect,  or  by  the  injection 
of  glycerin.  Only  when  this  is  of  no  avail  must  recourse  be  had 
to  the  vegetable  purgatives  {e.  g.,  Extr.  aloe,  Extr.  rhei.  comp.,  aa 
3.0 ;  adde  Succ.  liq.,  q.  s.,  ft.  pil.  30.  M.  One  to  two  pills  at  bedtime). 
Saline  purgatives  are  justly  objected  to,  since  they  weaken  the 
patient  to  a  remarkable  degree.  For  the  same  reason,  Penzoldt, 
Ewald,  and  Lebert  declare  that  drinking  cures  at  Carlsbad  and 
other  saline  springs  are  not  advisable.  This  prohibition  is 
generally  very  hard  for  those  patients  who  have  placed  all  their 
hope  on  a  sojourn  at  the  springs.  The  advice  of  Lebert  (quoted 
by  Ewald),  to  let  them  drink  small  quantities  of  the  mineral  water 
at  home,  is  very  practical,  for  generally  it  is  without  success,  and 
the  patient  will  then  willingly  give  up  a  trip  to  the  springs.  So  the 
treatment  in  a  nutshell  is  lavage,  tonics,  rest,  the  most  highly 
concentrated  and  nutritious  food,  whenever  it  is  too  late  or  im- 
possible to  operate. 

Prognosis. — If  the  diagnosis  can  be  made  early,  and  operative 
treatment  gives  fair  prospects  of  immediate  good  results,  there  is, 
as  we  have  seen  from  the  statistics  given  in  the  chapter  on  Surgical 
Operations  (pp.  336  to  357),  some  hope  of  prolonging  life.  But  if 
an  operative  interference  is  impossible  (see  the  contra-indications, 
p.  350)  or  refused,  the  disease  must  prove  fatal.  Careful  dietetic  and 
mechanical    treatment   may,   in    individual    cases,  prolong  life  for 


542  MALIGNANT    TUMORS    OF   THE    STOMACH. 

several  months.  In  cancerous  neoplasms  that  do  not  affect  the 
orifices,  the  immediate  danger  is  not  so  great.  We  have  ourselves 
reported  a  case  in  which  a  positive  diagnosis  of  malignant  tumor 
could  be  made  from  a  cancer  particle  that  came  up  in  the  wash- 
water  and  in  which  a  tumor  was  diagnosed  by  Da  Costa  and 
Musser  sixteen  months  ago.  At  this  date  (September,  1897)  the 
patient  is  still  doing  well,  is  free  from  pain,  and  enjoys  her  diet. 

LITERATURE  OX  CANCER  OF  THE  STOMACH. 

1.  Wm.  H.  Welch,  "  American  System  of  Medicine,"  vol.  11,  Article,  Cancer 
of  the  Stomach,  p.  53,  no  references. 

2.  Acker,  "  Zur  Pathogenese  der  Geschwulstmetastasen,"  Deutsches  Archiv 
f.  klin.  Med.,  xi. 

3.  J.  Arnold,  "  Ueber  Theilungsvorgange  in  den  Wanderzellen ;  ihre  progres- 
sive and  regressive  Metamorphose,"  Archiv  f.  mikr.  Anatomic,  xxx,  1887. 

4.  J.  Boas,  "Ueber  das  Vorkommen  von  Milchsaure  im  gesunden  und 
kranken  Magen,  nebst  Bemerkungen  zur  Klinik  des  Magencarcinoms,"  Zeit- 
schriftf.  klin.  Med.,  Bd.  XXV,  1894. 

5.  Dreyer,  "  Ueber  das  Magencarcinom."     Diss.     Berlin,  1894. 

6.  Ebstein,  "Ueber  Magenkrebs,"  Volkma7in's  Saminlung  klin.  Vortrdge, 
Nr.  87. 

7.  J.  S.  Ely,  "A  Study  of  :\Ietastat.  Carcinoma  of  the  Stomach,"  Americaii 
Journal,  June,  iBgo. 

8.  Ewald,  "  Krebs  der  Cardia  Metastase  im  rechten  Leberlappen  ;  Gastro- 
stomie,"  Deutsche  med.  Wochenschr.,  1889,  Xr.  23. 

9.  Feiertag,  "  Ueber  das  Verhalten  des  gesunden  und  kranken  Magens  be- 
zuglich  der  Milchsaurebildung  wahrend  der  Kohlenhydratverdauung,"  Jurjew- 
Dorpat,  1894. 

10.  Fischl,  "Die  Gastritis  beim  Carcinom  des  Magens,"  Prager  Zeitschr.f. 
Heilkunde,  1891. 

11.  Flatow,  "Ueber  die  Entwickelung  des  Magenkrebses  aus  Xarben  des 
runden  Magengeschwiirs."     Diss.     ■Nliinchen,  1887. 

12.  Friedreich,  "  Ein  Fall  von  Magenkrebs,"  Berl.  klin.  Wochenschr., 
1874. 

13.  Haberlin,    "Ueber  neue  diagnostische    Hiilfsmittel   bei   Magenkrebs," 

Deutsches  Archiv  f.  klin.  Med.,  1889,  Bd.  XLV. 

14.  Haberlin,  "  Verbreitung  und  Aetiologie  des  Magenkrebses,"  ^rf/^z'z//. 
klin.  Med.,  Bd.  XLiv. 

15.  Hanau,  "  Erfolgreiche  experimentelle  Uebertragung  von  Carcinom," 
Fortschritte  der  Med.,  1889,  Nr.  9. 

16.  Hanot,  "  Sur  une  forme  septicemique  du  cancer  de  I'estomac,"  Archiv 
gen.  de  Med.,  Sept.,  1892. 

17.  Hauser,  "Das  chronische  Magengeschwiir;  sein  Vernarbungs-Process 
und  die  Beziehung  zur  Entwickelung  des  Magencarcinoms,"  Leipzig,  1883. 

18.  Hauser,  "  Das  Cylinderepithelcarcinom  des  Magens  und  des  Dick- 
darms,"  Jena,  1890. 


BIBLIOGRAPHY    ON    GASTRIC    CARCINOMA.  543 

19.  V.  Hosslin,  "  Ueber  den  Einfluss  ungeniigender  Ernahrung  auf  die  Be- 
schaifenheit  des  Blutes,"  Mmichener  med.  Wochenschr.,  1890,  Nr.  38  und  39. 

20.  Hirsch,  "  Handbuch  der  histologisch-geographischen  Pathologic, "  Er- 
langen,  1 862-1 864. 

21.  Honigmann  und  v.  Xoorden,  "Ueber  das  Verhalten  der  Salzsaure  im 
carcinomatosen  Magen,"  Zeitschr.f.  klin.  Med.,  xiii. 

22.  Klebs,  Allgemeine  Pathologic  :  "  Ueber  das  Wesen  und  die  Erkennung 
der  Carcinombildung,"  Deutsche  med.  Wochenschr.,  1890. 

23.  Klemperer,  "  Ueber  den  Stoffvvechsel  und  das  Koma  der  Krebskranken,'' 
Berl.  klin.  Wochenschr.,  i88g. 

24.  Koch,  "  Ueber  das  Carcinoma  ventriculi  ex  ulcere  rotundo,"  Pctersbur- 
germed.  Wochenschr.,  1894. 

25.  N.  Kulneff,  "  Ueber  basische  Zersetzungsproducte  im  ?\lagen-  und  Darm- 
inhalt,"  Berl.  klin.  Wochenschr.,  1891,  Nr.  44. 

26.  Krukenberg,  "Ueber  die  diagnostische  Bedeutung  des  Salzsaurenach- 
weises  beim  Magenkrebs.     Diss.     Heidelberg,  1888. 

27.  Lannois  et  Courmont,  "Note  sur  la  coexistence  des  deux  cancers  primi- 
tifs  du  tube  digestif,"  Revue  de  Med.,  1894,  Nr.  4. 

28.  Lebert,  "Ueber  Magenkrebs  in  atiologischer  und  pathogenetischer  Be- 
ziehung,"  Deutsches  Archiv  f.  klin.  Med.,  1877,  Bd.  xxix. 

29.  O.  Leyhdecker,  "Ueber  einen  Fall  von  Carcinom  des  Ductus  thoracicus 
mit  chylosem  Ascites."  Inaug.-Diss.  Heidelberg,  1893,  Virchow's  Archiv, 
1893.  Bd.  cxxxiv. 

30.  Lepine  cf.  Mouisset,  "  Etude  sur  le  carcinome  de  I'estomac,"  Revue  de 
Med.,  1891. 

31.  V.  Limbeck,  "  Grundriss  einer  klinischen  Pathologie  des  Blutes,"  Jena, 
1896. 

32.  M.  Matieu,  "  Du  cancer  precoce  de  I'estomac."     These  de  Lyon,  1884. 

33.  M.  JMatieu,  "  Etat  de  la  muqueuse  de  I'estomac  dans  le  cancer  de  cet 
organ,"  Archiv  gen.  de  Med.,  1889. 

34.  Fr,  Miiller,  "  Stoffwechseluntersuchungen  bei  Krebskranken,"  Zeitschr. 
f.  klin.  Med.,  1889,  xvi. 

35.  Notthafft,  "Ueber  die  Entstehung  der  Carcinome,"  Deutsches  Archiv f. 
klin.  Med.,  Bd.  Liv,  1895. 

36.  Pianese,  "  Beitrag  zur  Histologie  und  Aetiologie  des  Carcinoms." 
(Deutsch  von  Teuscher.)     Suppl.  zu  Ziegler  s  Beitrdgen,  Jena,  1896. 

37.  Rauzier,  "  De  la  diminution  de  I'uree  dans  le  cancer.  Hypazoturie 
cancereuse."     These  de  Montpellier.     Ref.  in  Arch,  de  Med.  exp.,  1890. 

38.  Ribbert,  "Beitrage  zur  Histogenese  des  Carcinoms,"  Virchow's 
Archiv,  Bd.  cxxxv. 

39.  Ribbert,  "  Weitere  Beobachtungen  iiber  die  Histogenese  des  Carci- 
noms,"     Centralbl.f.  allg.  Pathologie,  v,  1894. 

40.  Riegel,  "  L'eber  die  therapeutische  Anwendung  der  Condurangorinde," 
Berl.  klin.  Wochenschr.,  1874. 

41.  Riegel,  "Beitrage  zur  Pathologie  und  Diagnostik  der  ]\Iagenkrank- 
heiten,  "Zeitschr.f.  klitt.  Med.,  xxxvi. 

42.  Riess,  "  Ueber  den  Werth  der  Condurangorinde  bei  dem  Symptomen- 
bild  des  Magencarcinoms,"  Berl.  klin.  Wochenschr.,   1887. 


544  MALIGNANT    TUMORS    OF    THE   STOMACH. 

43.  Rommelaere,  Journal  de  Med.  de  CJiir.  et  de  Pharm.  de  Bruxelles, 
1883-1886. 

44.  Rosenbach,  "Ueber  eine  eigenthiimliche  Farbstoffbildung  bei  schweren 
Darmleiden,"  Berlin,  klin.  Wochenschr.,  1889. 

45.  Rosenheim,  "  Ueber  atrophische  Processe  an  der  Magenschleimhaut  in 
ihrer  Beziehung  zum  Carcinom  und  als  selbstandige  Erkrankung."  Discussion. 
Eerl.  klin.  Wochenschr.,  1888. 

46.  Rosenlieim,  "  Zur  Kenntniss  desmit  Krebs  complicirten  runden  Magen- 
geschwiirs,"  Zeitschr.f.  klin.  Med.,  1890. 

47.  Schiile,  "  Beitrage  zur  Diagnostik  des  Magencarcinoms,"  Miinchener 
med.  Wochenschr.,  1894. 

48.  Senator,  "Ueber  Selbstinfection  durch  abnorme  Zersetzungsvorgange 
und  dadurch  bedingtes  dyskrasisches  Coma  (Kussmaul's  Symptomencomplex 
des  diabetischen  Comas)."     Zeitschr.f.  klin.  Med.,  1884,  vii. 

49.  V.  Sohlern,  "  Der  Einfluss  der  Ernahrung  auf  die  Entstehung  des 
Magengeschwiirs,"  Berl.  klin.  Wochenschr.,  1889,  Nr.  13  und  14. 

50.  Steinhaus,  "  Ueber  Carcinomzelleneinschliisse,"  Virchow's  Archiv, 
1 89 1,  Bd.  cxxvi. 

51.  Thoma,  "Ueber  eigenartige  parasitare  Mikroorganismen  in  den 
Epithelzellen  der  Carcinome,"  Fortschritte  der  Medicin,  1889,  Nr.  11. 

52.  Uffelmann,  "  Ueber  die  Methode  der  Untersuchung  des  Mageninhalts 
auf  freie  Salzsaure,"  Deutsches  Archiv  f.  klin.  Med.,  1880,  Bd.  xxvi. 

53.  Von  den  Velden,  "  Ueber  Vorkommen  und  Mangel  der  freien  Salzsaure 
im  Magensafte  bei  Gastrectasie,"  Deutsches  Archiv  fi'ir  klin.  Med.,  1879, 
Bd.  xxrii. 

54.  Virchow,  "  Bemerkungen  iiber  die  Carcinomzelleneinschliisse," 
Virchow's  Archiv,  1892,  Bd.  cxxvii. 

55.  Virchow,  "  Krankhafte  Geschwiilste,"  I. 

56.  R.  Volkmann,  "  Beitrage  zur  Chirurgie,"  Leipzig,  1875,  und  Deutsche 
Zeitschr.f.  Chirurgie,   1880,  Bd.  xiii. 

57.  Waldeyer,    Volkmann' s  Sammlung  klinischer  Vortrdge,  i,  Nr.  13. 

58.  Wazoldt,  "Ueber  einen  Fall  von  Absonderung  eines  ubermassig 
sauren  Magensaftes  bei  Magencarcinom,"  Charite  Annalen,  1888,  xiv. 

59.  Willigk,  Prager  Vierteljahresschrift,  vol.  x,  2,  1853. 

60.  W.  Brinton,  British  and  Foreign  Medico- Chirurgical  Review,  January, 
1857. 

61.  Wyss,  Blatter f.  Gesundheitspflege,  Zurich,  1872-74, 

62.  Jos.  D.  Bryant,  "  The  Wesley  M.  Carpenter  Lecture,"  New  York  Med. 
Jour.,  May  18,  1895. 

63.  Griesinger,  Archiv  f.  phys.  Heilkunde,  1854,  p.  528. 

64.  Heinemann,    Virchow'' s  Archiv,  vol.  lviii,  p.  180. 

65.  Eichhorst,  "  Lehrbuch  der  spec.  Pathol,  und  Therapie." 

66.  Debove,  Societe  med.  des  hopit.,  November,  1889. 

67.  Fox,  "The  Diseases  of  the  Stomach,"  London,  1872,  p.  184. 

68.  Menetrier,  Arch,  de  Physiolog.,  15.  Fevr.,  1888. 

69.  Scheuerlen,  "  Verhandl.  d.  Ver.  f.  innere  Medizin,"  Deutsche  med.  Wo- 
chenschr., 1887,  No.  48. 

70.  Coley.  Amer.  Jour,  of  the  Med.  Sciences,  1894. 


LITERATURE    ON    GASTRIC    CANCER.  545 

71.  Emmerich,  Deutsche  med.  Wochenschr.,  1895. 

72.  Katzenellenbogen,     "  Beitrage     zur    Statistik    des    Magencarcinoms." 
Inaug.-Diss.     Jena,  1878. 

73.  P.  Hampeln,  Zeitschr.f.  klin.  Med.,  Bd.  Vlii,  p.  232. 

74.  S,  Laache,  "Die  Anamie,"  Christiania,  1883. 

75.  Eisenlohr,  Deutsches  Archiv f.  klin.  Med.,  1895. 

76.  Cahn  und  von  Mehring,  Berl.  klin.  Woe henschr.,  1885. 

TJ.  Golding  Bird,  "  Contributions  to  the  Chemical  Pathology  of  some  Forms 
of  Morbid  Indigestion,"  London  Med.  Gazette,  1842,  p.  391. 

78.  W.  S.  Thayer,  >/^;z5  Hopkins  Hasp.  Bullet.,  1893,  No.  31. 

79.  Witzel,  Centralbl.  f.  Chirurg.,  1891,  No.  31. 

80.  Billroth,  Wiener  klin.  Wochenschr.,  1 891,  No.  34. 

81.  G.  Schneider,  Inaugural-Dissertation,  Berlin,  1888. 

82.  Schneyer,  Zeitschr.f.  klin.  Med.,  1895. 

83.  George  Dock,  A7ner.  Jour^i.  of  Med.  Sciences,  June,  1897,  p.  655. 


36 


^  i 

i  \ 

a 
X 

in 

H 

•< 

o 

i  = 

S.2 

'O  3 
1— 1  "-^ 

0 

g 

c 
1) 
3 
a- 

0    tn 

a 

a 
0 

<u 
a 

<    ^ 
3 

Gray-white     coat- 
ing ;    shows   impres- 
sion   of    teeth    fre- 
quently. 

tn~ 

<u 

[3 

iT    . 
^  a 

"3 

;-< 

G 

< 

May     be   present, 
but     not      regularly 
pronounced.      It    is 
rarely    actual    pain ; 
only     tenderness    of 
diffuse   character. 
Lancinating  pains  in 
atrophic   gastritis 
only. 

Q 
>• 
X 
oi 

o 
>J 
X 
u 

i  i 

.2 

a 

tuo 

a 
0 

H-1 

.s 

a 
1 

<0 

^^ 

0    . 

s 

C    X 

-a  lii  '^ 
S-H  ^    . 

0     r-     3 

Ut 

0 

a 

(Si 

u    . 

^  i: 

■5    G 
(U    <u 
-G  "S 

fl    •'   tn 

.2  .a  0 

c  2 

1) 

0 
_c 

G 

0 

g:-atn".2^^S  ■ 

a  .a   a   P-Ci  e  0  i:  g 

< 

3 

< 

a 
< 

o 

a 
o 

Id 

<u 

%^ 

&    ^ 

0    3 

0 

>^  (U 

cS    3 

u  ^ 

1^ 
<  S 

c 

lU 

a 
0 

c 
tu 

3 

cr 

•5  > 

'v 
"55  >- 
0  0 

C3 

oj 
UJ 
&, 
0-, 
CO 

a 

0 

C 
cJ 

S 
^     • 

■5 

"  T3 

.s  § 

.2 

c  a 

^     -'0 

la.B 

"S  0 

"IS 
> 

.a 

D 

<-< 

.2 

t>  0 
0 
6J0 

3    ^■"^"tn^ 

S    =    G    OJ    Jj    Ji 

u   „   0   j;   *"  c3 

Cu        3          "^    -H 

G    G  -^    ci  •;:  .£ 

G  «  i^      >  -5  3 

-^llaca 

-,  ^  S"  2  •-"  0  0 
2i  ^.a-S-S^i: 

u 

h 
■< 
O 

ii 

'S 

C 
1— 1 

n 
0 

a 
0 

S 

3 

cr 
<u 

<u     . 

0  11 

s  •• 

N 

_^'En    3 

3   bJO  " 
5  2  a 

.a  a  0 

ni    h    ^ 
iH    <->    (L) 

^     <L>     g     tu 

S.2  t« 

^•S  a 

tn    ^ 

r^    a    >~ 
t>    C     3 
^    tn  ij:; 

'6  '«  ^ 

0 

•-  tn    cS 

J=    CXI 

^•a  M 

•50.= 

C  X     !- 
■5   ■•-     >^ 

m  a  S 
3  3 

0  cr 

-^  "S  ^ 

^  cj  .a 

p,   TO 

rg    _CJ       3 

>^  C  T3    >>  C 

■z;  0  G  t:  ca 

v.            (U     U  XI 

i2^^i 

cj    (U    rt          (jH 
'-'           tn    ■"  OJ 
^  tn    1-  Td  i; 
a.  >   ra   0 

G  •'.:£  u  *: 

a;^T3   >  ^ 

G    tS    •  -  17:'    0    ^ 

3    I-    "^  t3          « 

ni  p,  0  c;  .5 

u 
•4. 
< 

!-^ 

cS 
<u 

r-. 

(U 

3    . 

0 

0 

■5 
0 

<u  • 

U) 

1) 
a 
C 

5i    . 

Qi    tn 

S    X 

tn 

-^    0 

<L>    ^ 

1i    *" 
rt    1) 

S5 
0  1^ 

13 
1) 
u 

a 

> 

-d 

G 

C3 

i) 
bxi 
ca 

0 
>-, 

0     . 

a-o 

0 
0 

>   >-    >-< 
?    cd    (U 

0    ctl 

tn    d  ■"" 
1)   >   c 

a,^  '3 
a.  0  p, 

bD  Q.'^, 

a      1-1 

.a  rt 

> 
"3 

;-• 

oi 

aT 

<  0 

0 

CI- 

•S  ^  >^  « 

2  s.a  0  § 

ii  "S  tu  '^  "So 

^  a  a  ^  i;s 

.i2   ■»-'  2    G    W) 
H  XI    tn  1  .5 

0-5  a  i 

2 

0 

H 
< 

» 

H 

u 
u 
z 

0 

H 

2 

0 

h 
< 

z 

a 
in 

u 
a* 

■5 

u 
-<  < 

546 


c 

a 

o 

si 

a  o 

cr  a 

tin    tn 

Rarely  fever ;  tem- 
perature    sometimes 
subnormal. 

S     . 
o    »-■ 

o 

a 

< 

u 

11 

<;  bx) 
_a 

Vomiting  frequent 
with  alcoholic  gnstri- 
tis ;    vomitus  matuti- 
nus. 

o 

Water- brash    and 
pyrosis    quite      fre- 
quent. 

u 

I-- 
> 

o 

Is 

e 

l-r 

o 

_a 

o 

> 

o  'a 

11    u 
in    tn 

<U    11 
;-<    ^ 
o    o 

.2  .S 

u  § 

^^^     a 

bjo 

.S 

s 

o 
> 

o 

a 
o 

u 

a, 
o 
12; 

a 

4) 
m 
9 

5, 
o 

> 

3 
> 

o 

"3 
S 
o 

o 

o 

bp 

E 
o 

> 

o 

,        CO 

^  a 

"^   o   rt 
.    cS    g 

U     O 

•zi  a 

.a, 

tl! 

.S 
>;> 

bo 

V. 

o 

a 

c 
_o 

o 

At  times  present ;   frecjuently 
water-brash     associated     with 
pyrosis. 

c 

(U 

CL, 
•"*    ;-i 

..,  o 

4-.  -a 
a  o 

cs  a 
«  o 

I-,    ra    ^    ^  „ 

s  °  i^-s 

oj   1)   u  *-'  -r 
>    o               g: 

i  s  s  'B  ^ 

o  ^2  ^  .5 
a  >  S  t,  lu 

O  ^  -S    O  J3 

13 

s 

5 

a 

JO 
C3 

b/3 

o 

•^            ^  rtj  r^  «  vh 

§1    s^  g  s  ^ 

3   ^        "  o  °  a  11 

Ucsiiar-U^^tT 

MaioaSor::g 
ci  33  a  g'S^-^l'C 

•z:  "^  ^2^  ^  ^  a  ^*^  S 
'g  o  "5  o    .  5  '5  ■"  cs 

cj 
(U 

tj 

if  s 

IS    o    g 

^J  a 

N    S 

a 
o 
o 

u 

is 
r-  It: 

S  <" 
g^  a 

C3 

u 
o 

a  "^ 
.2ti 
tS  2 
c2  " 

sH    cS 

No      water-brash ;       pyrosis 
quite  intense. 

<u  <u 
>  '5d 

^"^  c 

a  -a  o 

tn    s-    o 

^^-^^ 

2'B  S 

"  a    - 

a  Si 
O    C5i 

a  o  j 
<u       a 
S-o  -^ 
S:  a  1) 
a,  0)  42 

a  j;  ^ 

Ji-S  a 

rt    3 
.    ^  ts 

(U        C        i- 

i?  -^  ?=; 

TO              Q_ 

"  a  a 

t-    JJ    a;     . 
1)    1)  :_  — . 
>    ^  ^       cS 

cS  >>    •  § 
a  cx  o 
0  u:  a 

5 

a 

ci 

s 

o 

1) 

> 

o  ^ "      .S      ^1 
o.>^       S  o    .S 

■S  S  ^      3  'S  =^  g  o 
'S  §  S  d  «^  o  :n  o 'S 

^  "^    ^e2  ??  s/i'S 
•5  •£  .a      B  ^:b  E 

a-S  CO 

CS  1— 1     1) 

if  "■  1 

S          11 

"^■^ 

-^     "IJ     (U 

rt  G  5  s 

U  >^      i2 

V  "  t«  a 

H  la  tT  £ 

O     cS   i^ 

r'l  '"^  o  a 
c;°  a  o 

o  .a 
^  ,.r  a  iJ 
^-^  o-^ 

g  ^  rt      ij 

11  c.^^^^ 
a  t-  «  u 

U    O  "O    > 

u 
"a  S 

O     U 

.2  '° 
1  S 

^1 

z 

o 

< 

3 
p 

Pi 

Z 

> 

a 

< 

55 

a 
S 

H 
i- 

■>! 
S 
H 

O   0 

z 

i 

c 

> 

z 

0 
< 
o 

a 
CM 

547 


^         —   si 


c^ 


I-  -7^    1)    ^ 

o       ^ii 


U-; 


CX'o 


^oi 

S  go 

^  c 

^       i 

r,   =J   CJ 

r 

0 

0 

C    rt    S/3 

'^ 

te       c 

►-I  0  0 

£ 

0  "Xii 

tc 

■z  E       -5 


^"^ 

u 

4-1 

ci 

(U      !- 

■i^ 

s  0 

(^•d 

m    <u 

0    ^' 

■!-• 

CU  CJ 

1-^  >^— . 


.5  i  o 


-'  c  <*.  „ 

t=^    0    ^    _      !7    2 
t— I    Jn    o    -     1^    i; 


CJ2 
CJ    4J 


cy 


•^s 


■u  -r   S   Q 


^.      .  !«      ci 


o  <u  -^      •:: 


I  c 


"Hh?, -p 


;z;6 


ri  ^  ti 


--^  U  o 


^S-::  rt-S  i       -=  o        ^ 


s 


is  c  2 


c!  ^  ^ 


■SCO 


3  ~  —  1) 


CS     _ 

C\ 

ci 

^ 

'-c! 

0 

& 

a 

r:^  (u 

--  0 

0 

U 

0  j- 

3    c! 

.E'S 

w 

>, 

ki'iS 

^S 

0 

"w 

^-^      IE 


■  ij 

^ 

_ 

(1) 

«> 

:r! 

■Tj 

rt 

— 

£ 

C 

St 

<*H 

<n 

1) 

in 

0 

<U 

13 

Tl 

H 

:- 

C 

•- 

<u 

n 

n 

5 

a; 

0 

« 

c; 

OJ 

^( 

"rt 

CJ 

<u 

'^ 

5  S 


^  o 


iiz;      o 


c  < 


548 


CHAPTER  V. 

STOMACH   DISEASES  CAUSED  BY  INFECTIOUS 
GRANULOMATA. 

The  above-named  affections  have,  almost  exclusively,  a  purely 
pathological  significance.  Among  the  infectious  granulations  re- 
ported as  affecting  the  stomach  are  tuberculosis,  syphilis,  abdom- 
inal typhus,  glanders,  and  lymphadenoma.  We  will  consider 
gastric  tuberculosis  and  syphilis  separately. 

Typhoid  neoplasms  and  ulcerations  of  the  stomach  are  very 
rare;  even  more  unusual  than  tuberculous  ulcerations.  The 
medullary  swelling  of  lymph-glands,  however,  as  well  as  the 
ulcers  arising  therefrom,  have  been  described  as  occurring  in  the 
stomach  (Orth,  "  Specielle  pathol.  Anatomie,"  Bd.  i,  p.  714). 

Concerning  the  occurrence  of  glanders  in  the  human  stomach, 
only  one  observation  is  on  record,  viz. :  Bollinger  (O.  Wyss), 
"  Rotz,"  "von  Ziemssen's  Handb.,"  Bd.  iii,  p.  482,  1876. 

Leukemic  and  aleukemic  lymphadenoma,  as  occurring  in  the 
human  stomach,  have  been  reported  several  times.  ("  Lymphade- 
noma," Cornil  and  Ranvier,  "  Manuel  de  I'Histolog.  Patholog.," 
p.  294).  This  neoplasm  occurs  in  the  deeper  part  of  the  true 
mucosa  and  in  the  submucosa,  but  sends  prolongations  into  the 
outer  layers.  Lymphadenoma  and  glanders  may  ulcerate  on  the 
inner  surface  of  the  stomach. 

TUBERCULOSIS  OF  THE  STOMACH. 
The  gastric  mucosa  has  almost  entire  immunity  from  bacterial  in- 
fection. As  the  intestines  are  the  seat  of  frequent  infection,  when 
there  can  be  no  doubt  that  bacteria  have  entered  through  the  esopha- 
gus and  stomach,  the  immunity  of  the  last-named  organ  must  depend 
upon  some  peculiarity  in  its  structure  or  secretions.  Tubercle 
bacilli  are  not  affected  by  the  acid  gastric  juice,  as  has  been  proved 
by  Falk  {loc.  cit)  and  Frank  {loc.  cit?),  who  demonstrated  that  the 
growth  of  the  bacilli  could  not  be  retarded  by  the  gastric  secre- 
tion.    This  does  not  imply,  however,  that  these  bacilli  can  grow 

549 


550     STOMACH  DISEASES  CAUSED  BY  INFECTIOUS   GRANULOMATA. 

in  the  gastric  juice.  The  normal  stomach,  as  a  matter  of  fact,  is  not 
favorable  to  bacterial  development.  The  gastric  immunity  may 
further  be  accounted  for  by  the  scarcity  of  lymph-glands  in  the 
gastric  wall.  In  the  intestines  lymphatic  nodules  are  abundant, 
and  they  bear  some  definite  relation  to  the  formation  of  tubercle. 
The  occurrence  of  smaller  and  larger  tuberculous  foci  in  the 
stomachs  of  adults  and  children  proves  that  the  gastric  immunity 
can  not  be  complete.  Undoubtedly  a  number  of  conditions  must 
simultaneously  co-operate  to  bring  about  a  tuberculous  invasion. 
Prominent  among  these  are  :  (i)  A  lessened  resistance  or  reduced 
vitality  of  the  gastric  mucous  membrane.  (2)  A  diminished  secre- 
tion or  absence  of  HCl.  (3)  An  altered  state  of  the  blood. 
(4)  The  presence  of  tubercle  bacilli. 

A  number  of  the  tuberculous  gastric  ulcerations  that  are 
reported  have  developed,  not  from  a  direct  invasion  of  the  bacilli 
into  the  mucosa,  but  from  an  invasion  into  the  serosa,  occurring 
from  circumscribed  or  diffuse  peritonitis. 

Gastric  tuberculosis  occurs  in  two  forms  :  (i)  Miliary  tuberculosis 
of  the  wall  of  the  stomach,  a  not  uncommon  type;  (2)  tubercu- 
lous ulceration  of  the  stomach,  an  extremely  rare  occurrence. 
Miliary  tuberculosis  of  the  stomach  occurs  simultaneously  with  the 
eruption  of  tubercle  throughout  the  organism.  It  is  usually  found 
to  exist  with  a  miliary  tuberculosis  of  the  intestines  and  peritoneum. 
These  cases  may  strongly  resemble  intense  attacks  of  typhoid  fever. 
The  author,  while  physician-in-charge  of  Bay  View  Asylum,  Bal- 
timore, observed  two  cases  of  acute  miliary  tuberculosis  which 
were  diagnosed  as  typhoid  fever.  Even  the  characteristic  rose- 
spots  were  present.  This  was  at  a  time  when  microscopic  exam- 
ination for  tubercle  bacilli  was  not  in  vogue.  The  necropsies  were 
made  by  Prof.  William  T.  Councilman,  revealing  acute  miliary 
tuberculosis. 

The  immunity  of  the  stomach  from  tuberculosis  was  shown  in 
the  experiments  of  Orth  {loc.  cit.).  By  feeding  rabbits  with  tubercle 
bacilli  he  obtained  intestinal  tuberculosis  seven  times,  and  gastric 
tuberculosis  but  once.  In  a  case  of  tuberculosis  of  the  esophagus, 
reported  by  Dr.  S.  Flexner  {loc.  cit),  although  extensive  destruc- 
tion of  the  esophagus  existed,  and  the  pleural  cavity  had  been 
opened,  and  though  millions  of  tubercle  bacilli  must  have  been 
taken  into  the  stomach,  no  account  of  any  gastric  tuberculosis 
was  eiven. 


TUBERCULAR  GASTRIC  ULCERS.  55  I 

Clinically,  gastric  tuberculosis  is  without  much  significance.  It 
is,  as  a  rule,  not  diagnosticated.  Tuberculous  ulcerations  are  found 
most  frequently  in  the  p5'loric  part,  and  Orth  describes  isolated 
miliary  tubercles  occurring  in  the  vicinity  of  ulcerations.  In  rare 
cases  tuberculous  ulcerations  have  been  reported  to  produce  fatal 
symptoms  by  disintegrating  and  eroding  agastric  artery,  or  by  per- 
forating the  gastric  wall.  The  demonstration  of  the  tubercle  bacillus 
in  a  gastric  ulcer  was  first  made  by  Coats  {loc.  cit).  Matthieu  and 
Remond  {loc.  cit.),  Musser  [loc.  cii.),  and  Serafini  {loc.  cii.),  in  their 
cases,  also  succeeded  in  proving  the  presence  of  tubercle  bacilli. 
Kiihl  examined  for  the  tubercle  bacillus  in  four  cases  from  the 
Pathological  Museum  of  the  University  of  Kiel,  but  could  demon- 
strate it  positively  in  only  two  of  these,  which  were  recent  cases. 
The  other  two  were  older  specimens,  having  been  in  the  museum 
a  long  time.  A  large  number  of  the  reported  cases  of  tubercular 
ulcers  are  doubtful,  either  because  no  microscopic  examination  was 
made  at  all,  or  the  authors  failed  to  stain  for  the  bacillus.  Such 
cases  are  those  of  Paulicky  {loc.  cit)),  Hebb  {loc.  cit?),  Chvosteck 
{loc.  cit.,  4  cases),  Lange  {loc.  cit.),  Barlow  {loc.  cit.),  Quenu  {loc.  cit.), 
and  Bignon.  The  earliest  reported  case  of  tubercular  ulcer  is 
Litten's  {loc.  cit.),  which  showed  an  isolated  ulcer  on  the  anterior 
gastric  wall,  with  typical  giant  cells  and  caseating  tubercles. 
Letorey  {loc.  cit.)  recently  reported  a  case,  and  gave  an  analysis  of 
21  cases.  In  1887,  Marfan  reviewed  the  subject,  and  collected  14 
authenticated  cases.  The  disease  is  most  frequently  found  in 
males.  In  19  cases  collected  by  Letorey,  in  which  the  sex  was 
stated,  it  occurred  16  times  in  males  and  three  times  in  females.  The 
ulcers  are  usually  single.  In  a  case  from  Professor  Osier's  clinic, 
however,  at  the  Johns  Hopkins  Hospital  (parts  of  this  stomach  were 
presented  to  the  author  for  study  through  the  kindness  of  Dr.  S. 
Flexner,  who  performed  the  autopsy),  there  were  numerous  ulcers 
of  various  sizes.  In  this  case  the  intestines  were  also  the  seat  of 
numerous  ulcerations  penetrating  to  the  muscular  coat.  The 
stomach  showed  118  to  120  losses  of  substance  over  the  entire 
organ,  but  most  thickly  on  the  anterior  aspect  near  the  greater 
curvature.  Hermann  Diirck  {loc.  cit.)  observed  four  cases  of 
undoubted  tuberculous  ulcer  in  900  autopsies  at  Munich.  Frerichs 
and  Litten  have  reported  cases  in  which  the  tuberculous  ulceration 
was  limited  to  the  stomach,  the  intestines  being  intact.  The  sizes 
of  the  ulcers  vary  from  a  pin's  head  to  five  cm.  in  diameter.     Musser 


552      STOMACH   DISEASES  CAUSED  BY  INFECTIOUS  GRANULOMATA. 

{loc.  cit.)  has  reported  a  case  of  tuberculous  ulcer  3x1  inches  in 
extent ;  and  in  one  of  the  cases  of  Diirck  {loc.  cit.),  occurring  in  a 
child  ten  years  old,  there  existed  an  ulcer  exceeding  in  size  that  of 
a  German  5-Mark  piece  (somewhat  larger  than  a  silver  dollar). 
Secondary  tuberculous  changes  may  extend  to  the  stomach  through 
perforation  resulting  from  caseating  neighboring  lymph-glands. 
This  is  generally  rapidly  followed  by  purulent  processes  in  the 
glands.  When  the  peritoneum  of  the  stomach  becomes  involved 
in  a  general  peritoneal  tuberculosis,  the  posterior  wall  of  the  organ, 
which  is  probably  the  most  protected,  is  either  entirely  free,  or,  at 
any  rate,  it  is  much  less  affected  than  the  anterior  wall. 

Habershon  {loc.  cit.)  assumes  that  infection  of  the  gastric  mucosa 
occurs  by  way  of  the  vascular  channels.  He  does  not  believe  in 
a  direct  infection  of  the  mucosa  because  of  the  acidity  of  the  gastric 
juice.  Klebs  ("  Tuberculose,"  published  by  Leopold  Voss,  1894, 
p.  80)  assumes  that  tuberculous  new  formations  occur  on  the  basis 
of  pre-existing  gastric  ulcers.  A  critical  review  of  the  literature  is 
given  in  an  interesting  report  of  multiple  tuberculous  ulcers  of  the 
stomach  (three  cases,  by  Alice  Hamilton,  M..T).,/o/tns  Hopkins  Hos- 
pital Btilletin,  April,  1897). 

The  bibliography,  though  extensive,  is  not  quite  complete,  and 
we  have,  in  the  following,  added  cases  which  have  come  to  our 
notice.  In  these  three  cases  tubercle  bacilli  were  demonstrated  by 
the  Ziehl-Neelsen  method  of  staining.  Dr.  Hamilton  inclines  to  the 
opinion  of  Klebs,  that  gastric  erosions,  or  previously  existing  losses 
of  substance,  constitute  the  portals  of  entry  for  the  tubercle  bacillus. 
The  facts  in  the  second  case  indicate  that  many  small  erosions 
of  hemorrhagic  origin  pre-existed  in  the  stomach,  some  of  which 
became  invaded  with  tubercle  bacilli  swallowed  with  the  sputum. 
Perforation  not  infrequently  occurs.  It  was  present  six  times  in 
the  14  cases  reported  by  Marfan — three  times  through  a  tuber- 
culous gland.  In  eight  of  Letorey's  cases  the  presence  of  a  gastric 
tuberculosis  was  suspected  during  life  and  confirmed  at  the  necropsy. 
Death  by  perforation  peritonitis  resulted  in  a  case  reported  by 
Paulicky  {loc.  cit?).  Most  frequently  death  results  from  advanced 
tuberculosis  in  other  organs.  In  three  of  the  cases  death  was 
caused  by  severe  hemorrhage  following  an  erosion  of  a  blood-ves- 
sel through  the  ulcerative  process.  In  the  critical  consideration 
of  the  subject  by  Dr.  Hamilton  (loc.  cit?)  it  was  found  that  the 
authentic  literature  contained  15  undoubted  cases,  and  nine  more. 


HISTOLOGY    OF    GASTRIC    TUBERCULAR    ULCER.  553 

which  were  probable,  but  not  proven.  Wliile  there  is  a  dis- 
position for  development  of  tuberculosis  in  the  intestine,  there  are 
numerous  cases  reported  where  ulcers  existed  in  the  stomach,  the 
intestines  being  wholly  exempt.  The  deepest  ulcers,  when  found 
multiple  in  the  stomach,  do  not  extend  beyond  the  muscularis 
mucosa,  and  the  infiltration  of  the  mucous  membrane  extends 
little  further  than  the  actual  ulceration.  These  facts  are  very 
evident  in  the  sections  kindly  presented  to  the  author  by  Dr. 
S.  Flexner,  and  which  were  taken  from  the  cases  reported  by 
Dr.  Hamilton.  Superficial  small  ulcerations  still  showed  vestiges 
of  glands,  but  without  any  recognizable  distinction  between  oxyn- 
tic  and  chief  cells.  Epitheloid  and  lymphoid  cells  were  pro- 
fusely scattered  throughout  the  remnants  of  mucous  membrane. 
We  were  unable  to  detect  well-defined  and  typical  tubercles.  The 
free  surfaces  of  the  ulcers  were  in  a  state  of  necrosis,  covered  at 
times  by  a  homogeneous,  finely  granular  matter.  The  deeper  layers 
were  in  a  state  of  comparative  preservation.  Tubercle  bacilli  were 
present  in  small  numbers,  both  on  the  free  surface  of  the  ulcers  and 
among  the  remnants  of  the  glands.  Letulle  (Anatom.  Societe 
Paris,  1893;  also  abstracted  in  Ceiitralbl.  f.  allgeju.  Pathologie,  Bd. 
IV,  1893,  p.  760),  in  108  autopsies  on  undoubted  cases  of  pulmonary 
tuberculosis,  found  but  one  case  of  tuberculosis  of  the  stomach. 
The  organ  presented  ten  submucous  nodules  as  large  as  peas,  con- 
taining giant  cells  and  a  few  tubercle  bacilli. 

BIBLIOGRAPHY  ON  GASTRIC  TUBERCULOSIS. 

1.  Litten,   Virchow" s  Archiv,  1876. 

2.  Talamon,  Progres  Medical,  1879. 

3.  Brechemin,  Bull.  d.  I.  Soc.  Anat.,  May,  1879. 

4.  Eppinger, /Vflo-^r  z«i?^.  Wockensckr.,  1881.' 

5.  Barbacci,  I^  Speritnentale ,  May,  1890. 

6.  Coats,  Glasgow  Med.  Jour.,  1886. 

7.  Serafini,  Annal.  clt7t.  del  Osp.  di  Na.poli,  1888. 

8.  Mathieu  and  Remond,  in  Letorey's  Thesis,  Paris,  1875. 

9.  Musser,  Phila.  Hosp.  Reports,  1890,  I. 

10.  Kiihl,  Thesis,  Kiel,  1889. 

11.  G.  Hebb,  Westminster  Hosp.  Reports,  1888,  in, 

12.  Lava,  Gasz.  Med.  di  Torino,  1893. 

13.  Letorey,  These,  Paris,  1895. 

14.  Hattute,  Gaz.  des  Hop.,  1874. 

15.  Lorey,  Bull.  d.  I.  Soc.  Anat.,  1874. 

16.  Anger,  in  Marfan's  Thesis,  Paris,  1887. 

17.  Marfan,  These,  Paris,  1887. 


554      STOMACH  DISEASES   CAUSED  BY  INFECTIOUS   GRANULOMATA. 

i8.  Matthieu,  Bull.  d.  I.  Soc.  Anat.,  1881. 

19.  Cazin,  in  Fernet's  article,  Bull,  et  Mem.  d.  I.  Soc.  Med.  des  Hop.,  1880, 
tome  XVII. 

20.  Beadles,  British  Med.  Jour.,  1892,  ll. 

21.  Duguet,  in  Spillman's  These,  Paris,  1878. 

22.  Paulicky,  Berl.  klin.  Wochenschr.,  1867. 

23.  Chvostek,   Wien.  med.  Blatter,  1882,  v. 

24.  Lange,  "  Memorabilien,"  Heilbronn,  1871,  xvi. 

25.  Barlow,  Path.  Soc.  London,  1887. 

26.  Pozzi,  Bull.  Soc.  Anat.,  1868. 

27.  Labadie-Lagrave,  Bull.  Soc.  Anat.,  1870. 

28.  Oppolzer,  in  Marfan's  These,  Paris,  1887. 

29.  Ouenu,  in  Marfan's  These,  Paris,  1887. 

30.  Cordua,  "  Arbeiten  aus  dem  patholog.  Institut  in  Gottingen,"  Berlin, 
1893. 

31.  Falk,   Virc how's  Arc hiv,  Bd.  xcill,  p.  177,  1883. 

32.  Hermann  Diirck,  "  Ergeb.  d.  allgem.  Path."  (Four  cases  tuberculous 
ulcer  in  900  autopsies.) 

33.  LetuUe,  Anat.  Soc.  Paris,  1S93.     Centralbl.f.  Path.,  Bd.  iv,  p.  760. 

34.  Lubarsch  und  Ostertag,  vol.  11,  p.  336. 

35.  S.  Flexner,  "  Tuberculosis  of  Esophagus,"  Bull.  Johns  Hop.  Hos., 
No.  28,  1893. 

36.  Alice  Hamilton,  M.  Y).,  Johns  Hopkins  Hospit.  Bulletiji,  April,  1897. 

37.  Birch-Hirschfeld,   "  Lehrbuch  d.  path.  Anat.,"  Bd.  II,  S.  642. 

38.  E.  Prezewoski,  "Gastritis  tuberculosa"  (five  cases).  Centralbl.  f.  all- 
gem.  Path.  u.  path.  Anat.,  Bd.  vi,  S.  270. 

39.  S.  H.  Habershon,  Trans.  Path.  Soc,  London,  vol.  xlv,  p.  73. 

40.  Frank,  Deutsche  7ned.  Wochenschr.,  1884,  No.  20. 

41.  Orth,  "  Exper.  Magengeschw.,"    Virc  how's  Arc  hiv,  Bd.  Lxxvi. 

SYPHILIS    OF    THE  STOMACH. 

Pathological  changes  caused  by  syphilis  occur  in  the  stomach  in 
two  main  forms,  or  gummata  :  (ij  The  syphilitic  ulcer;  (2)  the 
syphilitic  neoplasms.  To  these  we  may  add  a  probable  third  form, 
(3)  the  diffuse  syphilitic  gastritis.  While  the  first  two  forms 
are  due  to  direct  syphilitic  disease,  the  third  form  ma}'  be  due 
to  indirect  syphilis  ;  for  instance,  to  the  formation  of  countless 
syphilitic  gummata,  forming  nodules  barely  visible  to  the  naked 
eye  in  the  mucosa  and  submucosa.  This  third  form,  in  the  majority 
of  cases,  is  probably  due  to  what  Chiari  terms  indirect  syphilis  ;  that 
is,  due  to  circulatory  disturbances,  passive  congestions,  hemorrhages, 
etc.,  produced  by  syphilitic  disease  of  other  organs,  especially  of 
the  liver. 

Gastric  disturbances  are  observed  in  individuals  affected  with 
syphilis,  even  at  an  early  prodromal   stage  of  cutaneous  eruptions. 


PLATE  IX. 


■  >-. 

^_j 

O    jj 

c5  o 

-'-' 

CS 

d   cj 

O 

<u 

3 

c 

^O 

o 

C    iJi 

dJ 

S 
N 

a 

3 

1) 

3    O 

be  OJ 

o  o 

tj 

a 

Ci 

r   2 

^  -^ 

o 

_^ 

rt   u 

t/1 

rt 

tfi 

Td   rt 

•2  3 

«  2 

O      „ 

a 

3 

a 

<u 
g 
3 

o 

"In 
O 

(U     OJ 

3 

G 

s^, 


^    S  I- 

"J    rr-( 


C    >-■  .E    «-i 

S  '5  'o  ■£ 

3    .     C 

S-S  t^  o 

>    <U 
'^^    en  '♦I 

!-  S  -2  1^ 

3    as    C 

■5.C  fe 


1^  ?f= 


0)    0)    o 
^    (U    bS 

<|.s 

S^  o 

u    C    ^ 

;i  ?  o 
3^  = 


^    fii    ^    rw  "-;    It* 


be  3 

5-5  M 


?     -^  Cj       >H 


o  ^  u  iJ 
'S  S  "*  '-" 


bjo  o  ^-5 
■5  W  3  "o 


b/)  rt    <u 
O  —    ^ 


™  • — '  r  >    c 


SYPHILIS    OF    THE    STOMACH.  555 

These  patients  may  develop  all  the  symptoms  of  acute  gastritis, 
with  a  feeling  of  pressure,  fullness  in  the  stomach,  loss  of  appetite, 
nausea,  etc.  The  symptoms  of  acute  or  subacute  gastritis  may 
be  accompanied  by  gastralgia,  coated  tongue,  headache,  and  actual 
vomiting.  These  symptoms  can  not  be  pronounced  as  syphilitic, 
because  other  etiological  factors  can  not  be  excluded ;  one  is  there- 
fore disposed  to  assign  the  gastric  symptoms  to  better  known 
causes.  Acute  diseases  of  the  neighboring  organs  (liver,  pancreas, 
and  spleen)  are  not  so  rare  in  syphilis  as  was  assumed  not  long 
ago.  Jullien  {loc.  cit)  describes  attacks  of  vomiting,  colic,  and 
diarrhea  in  the  course  of  recent  syphilis ;  and,  according  to 
Fournier  {loc.  cit.),  bulimia  is,  in  rare  cases,  a  symptom  in  severe 
forms  of  lues.  This  condition  is  observed  more  frequently  in 
women  than  in  men,  and  occurs  between  the  third  and  sixth 
month  of  the  disease.  According  to  this  author,  it  is  sometimes 
associated  with  polydipsia.  In  a  consideration  of  the  previous 
gastric  diseases,  we  have  seen  that  the  nerves  react  in  a  very  sensi- 
tive manner  to  certain  anomalous  states  of  the  blood — anemias, 
etc.  In  lues  we  have  characteristic  reduction  of  the  erythrocytes 
and  of  the  percentage  of  hemoglobin.  We  might  trace  the  symp- 
toms described  to  these  blood  conditions  in  preference  to  ascribing 
them  to  disease  of  the  gastric  mucosa. 

Chronic  Gastritis  Due  to  Syphilis. — This  is  a  rather  frequent 
and  important  syphilitic  affection,  and  is  one  of  the  main  causes  of 
the  poor  state  of  nutrition  in  luetics.  It  is,  as  a  rule,  associated 
with  characteristic  syphilitic  disease  in  other  digestive  organs 
(spleen,  pancreas,  and  liver).  Histologically,  it  may  be  found  to  be 
a  simple  chronic  gastritis,  or  else  combined  with  gummata  or 
gummatous  ulcers,  and  is  then  a  phenomenon  of  the  later  stages. 
Syphilitic  chronic  gastritis,  in  the  absence  of  gummata  or 
gummatous  ulcers,  does  not  differ  pathologically  from  ordinary 
chronic  gastritis.  The  cases  that  are  described  by  Virchow  [loc. 
cit?)  were  due  to  chronic  passive  hyperemia  caused  by  circulatory 
disturbances,  and,  in  our  opinion,  present  nothing  characteristic  of 
syphilitic  gastritis.  Chronic  syphilitic  gastritis  may  develop  from 
repeated  attacks  of  the  acute  form,  just  as  with  non-specific  chronic 
gastritis.     Relapses  need  not  necessarily  be  due  to  syphilis. 

If  characteristic  syphilitic  lesions  exist  in  the  liver,  kidneys, 
spleen,  pancreas,  or  intestines,  the  chronic  gastritis  should,  in  our 
opinion,  be  attributed  to  syphilis.     In  tertiary  syphilis  the  remark- 


556      STOMACH   DISEASES   CAUSED  BY  INFECTIOUS   GRANULOMATA. 

able  malnutrition  is  due  to  a  chronic  luetic  gastritis.  The  clinical 
phenomena  of  luetic  gastritis  are  not  different  from  the  non-specific 
inflammations  of  the  stomach. 

Diagnosis. — It  is  conceded  by  gastro-enterologists  that  iodids 
and  salts  of  mercury  have  a  deleterious  effect  upon  the  gastric 
functions  in  normal  individuals.  If,  therefore,  the  symptoms  of 
gastritis  develop  in  a  confirmed  luetic,  and  improve  upon  the 
administration  of  iodid  of  mercury,  getting  worse  when  the  mer- 
cury is  discontinued  and  improving  again  when  the  drug  is  re- 
sumed, the  diagnosis  of  chronic  syphilitic  gastritis  is  logical. 

We  have  observed  symptoms  of  acute  gastritis  in  a  child  eleven 
years  old,  daughter  of  a  man  who  had  contracted  syphilis  while 
he  was  a  soldier  in  the  German  army  in  the  Franco-Prussian  war, 
1 870-1 87 1.  The  father  of  this  child  has  had  maniacal  attacks,  in 
which  he  had  to  be  restrained.  Once  a  month  he  has  typical  epi- 
leptic convulsions,  which  may  last,  with  short  intervals,  for  ten  to 
twelve  hours,  with  foaming  at  the  mouth,  involuntary  evacuations, 
etc.  He  admits  the  original  infection,  and  gives  a  correct  history 
of  primary  and  secondary  syphilis.  The  child  recently  developed 
a  huge  gumma  of  the  lower  jaw,  which  assumed  the  dimensions  of 
a  goitre.  The  gastric  symptoms  were  incessant  vomiting  and  gas- 
tralgia.  By  treatment  with  mercurial  inunctions  the  stomach  symp- 
toms disappeared  in  the  course  of  two  weeks.  The  efficacy  of  this 
treatment  was  all  the  more  fortunate  since  the  child  could  retain 
nothing  on  its  stomach.  Two  years  ago  the  author  treated  another 
child  of  this  man  (his  wife,  by  the  way,  has  had  four  miscarriages),  for 
gastralgia,  nausea,  eructations,  and  vomiting,  by  a  saturated  solution 
of  iodid  of  potassium.  The  child  took  as  much  as  40  drops  of  the 
saturated  solution  of  KI  three  times  a  day,  with  evidences  of  distinct 
improvement,  the  symptoms  subsiding  entirely  at  the  end  of  two 
weeks.  Tullio  {Joe.  cit.)  reports  improvement  and  cure  of  severe 
chronic  gastritis  by  iodid  of  mercury  given  internally.  The  patient 
became  worse  when  the  mercury  was  discontinued.  Non-s}^phil- 
itics  were  made  dyspeptic  by  taking  iodid  of  mercury.  The 
following  conclusions  appear  to  us  to  be  logical.  When 
digestive  disturbances,  resembling  those  of  gastritis,  occur  in  a 
syphilitic,  and  other  etiological  factors  can  be  excluded,  the  diag- 
nosis of  syphilitic  gastritis  is  correct  if  the  phenomena  disappear 
under  anti-syphilitic  treatment.  The  diagnosis,  then,  depends  upon 
the  evidence  of  undeniable  syphilis  as  a  cause,  and  the  disappear- 


HISTOLOGY    OF    SYPHILITIC    GASTRITIS.  55/ 

ance  of  gastric  symptoms  under  anti-syphilitic  treatment.    Professor 
S.  Flexner  (pathologist  to  the  Johns  Hopkins  Hospital)  presented 
us  with  the  stomach  of  a  syphilitic  negro,  who  had  gummata  in  the 
following  places  :  (i)  Frontal  bone,  extending  into  the  meninges  and 
frontal  cerebral  convolutions  ;    (2)   one  in  the  liver ;   (3)  one  in  the 
spleen;  (4)  three  in  mesenteric  glands;  (5)  one  in  the  testes  and  epi- 
didymis.    The  author  was  present  at  the  autopsy,  which  was  made 
by  Dr.  Flexner,  but  did  not  see  the  patient  prior  to  his  death.  After 
hardening  in  formol,  the   sections  were  stained  in  orange  G.  and 
hematoxylin.     All  the  sections,  no  matter  from  what  portion  of  the 
stomach  they  were  taken,  showed  an  intense  diffuse  gastritis.     At 
first  we  failed  to  find  characteristic  evidence  of  lues.     The  surface 
of  the  mucosa  was  covered  with   finely  granular  elevations,  quite 
evident   to    the    naked    eye.     The    surface    cylindrical  epithehum 
was  lost    entirely.     There  was    a    very  characteristic    endarteritis 
and  thickening  of  the  vessel  walls,  producing    occlusion   of   the 
lumen  (endarteritis  obliterans).     Throughout  the  mucosa  and  sub- 
mucosa  were  countless  miliary  nodules,  about  the  size  of  a  pin's 
head,  composed  of  apparently  densely  packed  collections  of  small 
round   cells.     Some  of  these  nodules  exhibited  themselves  in  the 
submucosa,  but  in  that  situation  they  were  rare.     The    majority 
of  them  rested  upon  the  muscularis  mucosae,  and  thence  extended 
upward  into  the  glandular  layer,  pushing  apart,  compressing,  and 
distorting  what  was  left  of  the  gland   ducts.     Some  of  the  small 
round-celled  infiltrations   resembled    normal   lymph-glands  of  the 
stomach.    The  majority  of  them  were,  however,  larger  than  the  gas- 
tric lymph-glands,  extending  from  the  submucosa  to  the  surface  of 
the  mucous  membrane  (see  illustration,  Plate  ix).    One  of  our  artists 
(Mr.  Louis  Schmidt)  has  given  a  graphic  illustration  of  the  condi- 
tion present.     In  many  places  collections  of  round  cells  had  forced 
asunder  the  fibers  of  the  muscularis  mucosae,  splitting  apart  this 
layer,  which  usually  runs  along  in  one  stratum.    In  some  places  the 
muscularis  mucosae  was  seemingly    torn  apart    and  forced  either 
downward  into  the  submucosa,  or  upward  into  the  mucosa,  in  large 
bundles,  by  infiltrating  masses  of  round  cells.     The  longitudinal 
layer  of  muscle-fibers  was  similarly  split  up  by  enormous  collec- 
tions of  small  round-cell  infiltration.     The  fibers  of  the  muscularis 
mucosa  normally  ascend  into  the  glandular    layer  and  surround 
the  gland  tubules.     We  have,  however,  never  seen  these  muscle- 
fibers  ascending  in  such  masses  as  in  these  specimens.     In  places. 


558      STOMACH   DISEASES   CAUSED  BV  INFECTIOUS   GRAXULOMATA. 

the  entire  glandular  layer  was  replaced  by  a  mass  of  small  round 
cells.  To  the  left  of  the  illustration  is  represented  one  of  the 
miliary  nodules,  showing  a  gradual  breaking  down  or  softening  at 
the  side.  Although  at  first  inclined  to  consider  this  whole  process 
due  to  indirect  syphilis,  caused  by  passive  congestion  due  to  the 
luetic  hepatitis  (a  large  gumma  being  present  in  the  liver),  the 
finding  of  nodules,  as  large  as  a  pin's  head  (which  showed  signs 
of  softening),  suggests  that  we  may  possibly  be  dealing  with 
minute  miliary  gummata.  Chiari  {loc.  cit.)  reported  243  autopsies 
on  undoubted  syphilitics  ;  145  were  hereditary  and  98  acquired 
syphilis.  His  conclusions  are  the  following:  (i)  Pathological 
changes  caused  by  syphilis  really  occur  in  the  stomach  ;  (2)  they 
may  be  direct  syphilitic  changes,  or  owe  their  origin  indirectly  to 
syphilis ;  (3)  the  direct  syphilis  of  the  stomach  is  a  great  rarity, 
and  is  either  a  gummatous  process  or  a  simple  inflammatory  infil- 
tration ;  the  latter  occurs  only  in  the  hereditary  form  ;  (4)  the  indi- 
rect syphilitic  affections  of  the  stomach  are  due  to  circulatory 
disturbances  caused  b}'  syphilis  of  the  other  organs,  especially  of 
the  liver,  or  else  they  are  due  to  gastric  hemorrhages  occurring 
interstitially  as  phenomena  of  a  syphilitic-hemorrhagic  diathesis ; 
(5)  gummous  processes  in  the  stomach  are  characterized  by  pres- 
ence of  gummatous  tissues  ;  they  are  first  developed  in  the  sub- 
mucosa,  and  enter  the  other  layers  from  there  ;  (6)  syphilitic  gastric 
ulcers  may  be  caused  by  disintegration  and  autodigestion.  The 
cicatrices  in  the  stomach  demonstrated  by  Cornil  {loc.  cit)  and 
Weichselbaum  {loc.  cit)  could  be  attributed  to  syphilis  only  if  gum- 
matous tissue  were  present,  or  other  non-ulcerating  gummata" 

Only  in  three  cases  could  Chiari  designate  the  changes  as  direct 
syphilis — one  gumma  in  a  case  of  hereditary  syphilis,  one  gumma 
in  a  case  of  acquired  syphilis,  and  one  in  diffuse  inflammatory 
infiltration  of  the  mucosa  and  submucosa  in  hereditary  syphilis. 
His  percentage  of  gastric  syphilis  was  1.2  per  cent,  of  the  total 
material  of  243  sections, — 1.3  percent,  in  hereditary  syphilis  and 
1.2  per  cent,  of  acquired  syphilis. 

Syphilitic  Ulcers  of  the  Stomach. — In  a  study  of  the  sub- 
joined literature,  authentic  cases  of  syphilitic  gastric  ulcers  are 
not  so  scarce  as  one  might  presume.  Galliard  {loc.  cit)  and 
Cruveilhier  {loc.  cit.)  were  disposed  to  believe  in  a  causative  rela- 
tion between  simple  gastric  ulcer  and  syphilis.  Among  100  cases 
of  gastric  ulcer,  Engel  could  trace  a  syphilitic  history  in  ten  per 


GASTRIC    ULCER    RESULTING    FROM    SYPHILIS.  559 

cent.  T.  Lang  {loc.  cit.)  stated  that  20  per  cent,  of  gastric  ulcers 
occur  in  syphilis.  Ewald  expresses  himself  with  doubt  on  this 
subject.  "  It  must  remain  questionable,"  he  says,  "  in  two  diseases 
as  common  as  those  under  discussion,  whether  we  are  dealing 
with  cause  and  effect,  or  with  accidental  coincidents."  Frerichs, 
Drozda,  Murchison,  and  Chvostek  found  scars  in  the  stomach, 
coincidently  with  general  syphilis.  Gastric  ulcers  may  occur  in 
syphilitics  from  necrosis  of  the  mucosa,  due  to  specific  endarteritis, 
or  to  disintegration  and  breaking  down  of  a  gumma.  In  1838 
Andral  {loc.  cit.)  concluded  that  a  gastric  ulcer  in  his  clinic  was 
due  to  syphilis  because  it  was  cured  by  mercurial  treatment. 
Rosanow  {loc.  cit.)  described  a  case  in  a  soldier  who  had  suffered 
from  gastric  ulcer  for  eight  years  and  had  been  treated  by  him  for 
two  months  by  typical  ulcer  treatment.  The  cardialgia,  however, 
continued,  and  was  associated  with  pains  in  the  lower  extremities. 
The  patient  showed  no  signs  of  lues.  He  was  cured  in  forty-seven 
days  by  treatment  by  inunctions  and  iodid  of  potassium.  It  is 
necessary  to  distinguish  between  typical  simple,  round  ulcers 
occuring  in  syphilitics,  and  gummatous  ulcerations,  with  gastritis. 
According  to  Wagner  {loc.  cit.)  and  Klebs  {loc.  cit),  all  ulcers  found 
in  the  stomachs  of  syphilitics  have  arisen  from  gummata,  but 
Galliard  {loc.  cit),  Lang  {loc.  cit),  and  Mauriac  {loc.  cit.)  differ  from 
this  opinion,  and  hold  that  the  syphilitic  gastric  ulcers  need  not 
necessarily  arise  from  gummata. 

Neumann  {loc.  cit.)  asserts  that  syphilis  is  more  often  the  cause  of 
gastric  ulcer  than  has  been  hitherto  believed ;  furthermore,  that 
gastric  ulcer  and  syphilis  do  not  all  develop  from  gummata,  but 
have  the  same  manifold  etiology  as  the  non-specific  ulcer.  They 
may  develop  from  erosions,  which  are  very  frequent  in  syphilitics, 
from  endarteritis,  diminution  in  the  amount  of  hemoglobin,  and 
reduction  of  the  alkalinity  of  the  blood,  increase  and  disintegra- 
tion of  the  leukocytes.  These  states  are  characteristic  of  lues,  and 
are  accepted  as  etiological  factors  of  round  ulcers  also.  To  these 
might  be  added  hyperacidity  and  bacterial  infection  causing  necro- 
sis. In  a  case  of  Fauvel's  {loc.  cit),  the  stomach  showed  chronic  gas- 
tritis and  several  ulcers.  In  a  case  of  Capozzi's  {loc.  cit),  numerous 
ulcerations  of  the  mucosa  extended  from  the  cardia  along  the 
greater  curvature  to  the  pylorus.  In  a  case  of  Oser's,  the  patient 
was  affected  with  a  syphilitic  papulous  eruption  and  psoriasis  pal- 
37 


560      STOMACH   DISEASES  CAUSED  BY  INFECTIOUS   GRANULOMATA. 

maris,  the  gastric  mucosa  was  injected  and  permeated  by  numerous 
hemorrhagic  erosions. 

The  syniptovis,  course,  and  terviination  of  s)'philitic  gastric  ulcers 
are  not  different  from  the  non-syphilitic.  In  a  case  of  Rosanow's 
{loc.  cit),  the  gastralgia  occurred  only  at  night,  and  from  this 
the  author  diagnosticated  the  probable  syphilitic  nature  of  the 
ulcer.  Bartumeus  {loc  cit)  speaks  of  nightly  vomiting  occurring 
with  syphilitic  ulcer. 

Diagnosis. — When  other  etiological  factors — such  as  tuberculosis, 
alcoholism,  chlorosis,  and  the  manifold  causes  which  we  have 
enumerated  in  the  article  on  ulcer — can  be  excluded,  and  undoubted 
syphilis  can  be  established,  the  diagnosis  of  the  syphilitic  origin  of 
gastric  ulcer  might  be  made,  although  not  with  certainty.  The 
diagnoses  of  Andral  {loc.  cit.),  Hayem  {loc.  cit),  and  Marc  {loc.  cit), 
were  based  upon  the  curative  effect  of  antisyphilitic  treatment. 

Prognosis. — Wagner  {loc.  cit),  Lanceraux,  and  others,  report  cures 
of  syphilitic  ulcers  by  iodid  of  potassium.  The  conditions  after  the 
reported  cures  were  similar  to  those  existing  after  the  cures  of  non- 
specific ulcers.  Stenosis  of  the  stomach  and  chronic  gastritis,  fol- 
lowing syphilitic  ulcers,  have  been  observed  by  Cornil,  Capozzi, 
Wagner,  Fauvel,  and  Klebs.  The  direct  cause  of  death  in  autopsies 
of  cases  of  syphilitic  gastric  ulcers  hitherto  reported  was  plainly 
attributable  to  pathological  states  in  other  organs,  such  as  tuber- 
culosis, amyloid  and  fatty  degeneration  of  various  viscera,  dropsies, 
and  edema.  Some  of  the  cases  reported  as  syphilitic  are  doubtful. 
This  is  our  opinion  of  the  case  reported  by  Zavadski  and  Luxen- 
bourg  {loc.  cit),  in  which  no  characteristic  syphilitic  lesions  are 
described,  as  the  endarteritis  and  the  small  round-cell  infiltration 
may  occur  in  chronic  gastritis  of  a  non-luetic  character.  The 
patient,  a  medical  student,  had  denied  luetic  infection. 

Syphilitic  Neoplasms  of  the  Stomach. — The  percentage  of 
gastric  gummata  occurring  in  syphilis  has  already  been  stated  in 
the  results  given  from  243  autopsies  on  syphilitics  performed  by 
Chiari  {loc.  cit). 

Gastric  gummata  have  been  described  by  Galliard  {loc.  cit), 
Cornil  {loc.  cit),  Birch-Hirschfeld  {loc.  cit),  Chiari  {loc.  cit),  Wagner 
{loc.  cit),  Klebs  {loc.  cit),  and  Lanceraux  {loc.  cit.).  Cornil's  case, 
which  may  be  regarded  as  typical,  was  that  of  a  woman  who  had 
gummata  both   in   the  liver  and  stomach.     That  in  the  stomach 


SYPHILITIC    NEOPLASM.  56 1 

Xvas  located  on  the  lesser  curvature,  and  had  the  appearance  of  a 
flattened  reddish  tumor,  two  to  five  cm.  in  diameter.  The  gastric 
gummata  reported  by  Chiari  {loc.  cit.)  were  sharply  circumscribed 
elevated  swellings.  They  occur  together  with  gastric  or  intestinal 
ulcers  or  cicatrices,  and  develop  in  the  submucous  layer  as  dense, 
compact,  felt-like  masses,  formed  of  fasciculi  of  connective  tissue 
infiltrated  with  small  round  cells.  From  the  submucosa  they 
advance  into  the  serosa  and  mucosa.  The  mucosa  is  thickened, 
smooth,  and  glistening,  and  of  a  pale  yellow  color.  The  mus- 
cularis  and  the  serosa  are  also  thickened.  The  condition  of  the 
gummata  will  vary  with  the  stage  in  which  they  are  found.  In  one 
case  Cornil  found  three  gummata,  respectively  two,  three,  and  five 
cm.  in  diameter,  in  the  neighborhood  of  the  pylorus.  The  mucosa 
oyer  these  gummata  was  thinned  out  and  adherent.  Lanceraux 
{loc.  cit^  found  an  ulceration  30  cm.  in  diameter  in  close  proximity 
to  the  pylorus  on  the  lesser  curvature.  The  case  was  that  of  a 
man  sixty-six  years  old,  with  many  manifestations  of  syphilis. 
The  ulceration  had  destroyed  the  gastric  wall — thinned  it  down 
to  a  very  delicate  lamella.  The  nodule  was  in  a  state  of  fatty 
disintegration,  and  apparently  had  prevented  a  perforation  by  its 
own  structure.  Birch-Hirschfeld's  case  occurred  in  a  newborn 
infant,  with  skin  syphilis  and  a  gumma  in  the  liver  and  lungs. 
In  the  pylorus  was  a  slightly  elevated  thick  area,  as  large  as  the 
palm  of  the  hand.  It  was  of  a  whitish  color  and  of  tolerably  firm 
consistence,  formed  of  granulation  tissues  infiltrated  with  masses 
of  small  round  cells.  Weichselbaum  [loc.  cit.)  described  two 
ulcers  and  one  cicatrix  at  a  spot  where  the  transition  of  the 
fundus  into  the  pyloric  part  occurs.  One  of  the  ulcers  had  a 
triangular  shape  and  was  12  mm.  long.  This  occurred  in  a  man 
twenty-five  years  old,  with  syphilitic  manifestations  of  the  cranium, 
nose,  throat,  larynx,  and  liver.  Another  case  of  Chiari's,  a 
child  three  weeks  old,  with  pemphigus  syphiliticus,  swelling  of 
the  inguinal  glands,  and  fissures  in  the  lips,  tongue,  and  penis, 
showed  in  the  lungs  numerous  nodules  as  large  as  peas,  some  as 
large  as  hazelnuts.  There  was  an  induration  in  the  hilus  of 
the  liver,  and  a  similar  callosity  on  the  common  duct,  and  also  on 
the  cystic  duct.  The  wall  of  the  gall-bladder  neck  was  strongly 
infiltrated.  The  gastric  mucosa  showed  five  plate-like  gummata. 
The  gastric  gummata  generally  soften,  break  down,  and  ulcer- 
ate ;  this  has  been  the  cause  of  assigning  all  syphilitic  ulcers  to 


562      STOMACH   DISEASES  CAUSED  BY  INFECTIOUS   GRANULOMATA. 

the  breaking  down  of  gummata.  The  ulcer  which  arises  from  a 
gumma  is  a  loss  of  substance  that  is  smaller  in  the  true  mucosa 
than  in  the  submucosa.  The  simple  perforating  gastric  ulcer  is 
a  loss  of  substance  that  is  greatest  in  the  true  mucosa,  becomes 
smaller  in  the  submucosa,    and    still   smaller    in    the    muscularis. 

This  gives  the  simple  gastric  ulcer  the  characteristic  terraced 
appearance,  which  is  never  seen  with  a  gummatous  gastric  ulcer. 
The  edge  of  the  simple  gastric  ulcer  is  not  undermined,  but  has 
the  appearance  as  if  cut  out  with  a  punch.  The  edge  of  the 
gummatous  gastric  ulcer,  however,  is  irregular,  angular,  and  rolled 
up.  The  surroundings,  the  walls,  and  the  floor  of  the  simple  gas- 
tric ulcer  exhibit  no  pus  and  no  necrotic  tissue  elements  ;  perhaps 
some  slight  hemorrhagic  infiltration  is  observable,  if  a  previous 
hemorrhage  has  occurred.  The  gummatous  gastric  ulcer  is  covered 
by  a  yellow,  tough,  gelatinous  deposit.  In  the  surroundings  one 
frequently  finds  gummata.  Old  and  extensive  simple  ulcers  may 
closely  resemble  gummatous  ulcers  on  account  of  the  fibrous 
thickening  of  the  edges.  The  occurrence  of  gummata  in  other 
parts  of  the  digestive  tract  or  organs  may  then  decide  the  nature 
of  the  gastric  neoplasm.  Gummata  of  the  stomach,  according  to 
Neumann,  are  manifestations  of  late  lues.  The  cases  of  Birch- 
Hirschfeld  {loc.  cit)  and  Chiari  {loc.  cit.),  however,  were  inherited 
syphilis. 

Diagnosis. — These  lesions  do  not  give  symptoms  sufficiently 
characteristic  to  make  their  clinical  recognition  possible.  In 
pronounced  syphilitics,  with  palpable  hepatic  gummata  and  steno- 
tic symptoms  in  the  stomach,  antisyphiiitic  treatment  may  possibly 
give  some  clue  regarding  the  nature  of  the  gastric  neoplasm. 

Hemorrhage  from  the  Stomach  as  a  Result  of  Syphilis. 
— This  is  an  extremely  rare  occurrence.  Hayem  reports  a  case  of 
grave  hematemesis  which  baffled  the  usual  treatment,  but  ceased 
after  the  administration  of  iodid  of  potash.  Gastric  hemorrhage 
may  occur  as  a  result  of  intense  passive  congestion,  caused  by 
obstruction  of  the  portal  circulation.  }r{\\\tv[loc.cit.)  reports  a  case 
of  a  man  thirty-nine  years  old,  who  admitted  having  acquired 
lues  in  1868.  In  the  night  from  the  3d  to  the  4th  of  December, 
1 88 1,  he  vomited  large  quantities  of  blood,  and  passed  blood  by  the 
stool.  On  the  5th  of  December,  the  vomiting  of  bright  red  blood 
was  repeated ;  he  also  had  three  passages  that  were  black  with 
partially  digested  blood.     The  gums  and  uvula  were  covered  with 


LITERATURE    ON    GASTRIC    SYPHILIS.  563 

numerous  radiating  scars ;  the  pharynx  showed  two  recent  scars. 
In  the  nasal  partition  there  was  an  irregular,  deepened  ulcer  with 
callous  edges.  For  several  months  there  had  been  a  purulent 
offensive  discharge  from  the  nose.  There  was  decided  enlarge- 
ment of  the  spleen  and  liver.  Several  uneven  prominences  were 
palpable  on  the  surface  of  the  liver.  The  diagnosis  of  syphilis  of 
the  liver  was  made,  with  passive  congestion  in  the  spleen  and 
stomach.  The  patient  recovered  under  antisyphilitic  treatment. 
It  is  impossible  to  decide  in  these  cases  whether  the  hemorrhage 
comes  from  an  ulcer,  from  hemorrhagic  erosions,  or  from  disease 
of  the  blood-vessels. 

BIBLIOGRAPHY  ON  SYPHILIS  OF  THE  STOMACH. 

1.  L.  Jullien,  '-'  Traite  Pratique  des  Malad.  Vener.,"  1879,  P-  ^^S- 

2.  Fournier,  "  Notes  sur  Certains  Cas  Curieux  de  Boulimie  et  de  Polydipsia 
d'Origine  Syphillitique,"  Gaz.  hebdomadaire  de  Med.  et  de  Chirurg.,  Paris, 
1871,  Nos.  I  and  2;  Gaz.  des  Hopitaux,  Paris,  1871,  Nos.  109,  no,  112. 

3.  Virchovv,  "  Handb.  derspec.  PathoL  und  Ther.,"  xr,  i,  S.  71,  78. 

4.  Orth,  "  Lehrbuch  d.  speciellen  pathol.  Anatomie,"  Berlin,  1887,  i,  S.  709, 

744- 

5.  T.  Lang,  "  Zur  Lelire  von  der  Eingeweidesyphilis,"  Sonderdruck  der 
Wienermed.  Presse,  1885,  No.  11. 

6.  V.  Rosanow,  "  Magengeschwiir  syphilitischen  Ursprungs,"  La  Seinaine 
Medicale,  1890,  No.  43. 

7.  Klebs,  "  Pathologische  Anatomie,"  1869,  i,  262,  263. 

8.  Galliard,  "Syphilis  Gastrique  et  Ulcere  Simple  de  I'Estomac,"  Archives 
Generales  de  Medicine,  1886,  pp.  66-83. 

9.  Mauriac,  "  Syph.  tert.,"  p.  723. 

10.  V.  Jaksch,  Cit.  nach  Bamberger,  "Krankheiten  des  chylopoetischen 
Systems,"  "  Handb.  d.  spec.  Pathologie  u.  Therapie,"  von  Virchow,  vi, 
I.  Abth.,  280. 

11.  Berthold's  "  Statistischer  Beitrag  zur  Kenntniss  des  chronischen 
Magengeschwiirs."  Aus  den  SectionsprotokoUen  des  patholog.  Institutes  zu 
Berlin,  1868-1882.    Berlin,  1883  ;    Dissertation. 

12.  Nolle,  "  Ueber  die  Haufigkeit  des  Magengeschwiirs  in  Miinchen." 
Miinchen,  1883  ;   Dissertation. 

13.  Oser's  Vierteljahresschrifi  fi'ir  Dermatologie  tend  Syphilis,  1871,  No.  27. 

14.  Neumann,  in  "  Nothnagel's  specielle  Patholog.  u.  Therapie,"  Bd. 
XXIII,  Syphilis,  S.  351. 

15.  Capozzi,  II  Morgagni,  1867,  ix,  2,  89;  Schmidt's  Jahrbiicher,  cxxxv,  41. 

16.  Fauvel,  Bullet,  de  la  Societe  d'Anatom,  1858, 

17.  Bartumeus,  "  Gastralgia  Intermittente  Sifilitica  Accompananda  de  Vom- 
itos  Vespertinos  y  Otros  Accidents  Especificos  Dolorosos,"  Revista  de  Ciencias 
Med.,  Barcelona,  1878,  348. 

18.  Andral,  Clinique  med.,  tome  IV,  121. 


564     STOMACH    DISEASES  CAUSED  BY  INFECTIOUS   GRANULOMATA. 

19.  Hayem,  G.  Hayem  et  Tissier,  "  De  la  Syphilis  de  I'lntestin,"  Revue  de 
Med.,  Paris,  1889,  231. 

20.  Wagner,   "  Das  Syphilom,"  Archiv  der  Heilkiinde ,  1863,  Bd.  iv,  369, 
225,  and  226. 

2r.  Lanceraux,  "  Traite  Historique  et  Pratique  de  la  Syphilis,"  Paris,  1873, 
S.  249. 

22.  Lanceraux,  "  Traite  de  la  Syphilis,"  1874,  248. 

23.  Cornil,  "  Le9ons  sur  la  Syphilis,"  1879,  4°^'  ^"^^  "  Manuel  de  I'Histolog. 
Patholog.,"  1882,  II,  296. 

24.  Chiari,  Prager  7ned.  Wocheiischr.,  1885,  No.  47. 

25.  Birch-Hirschfeld,  "  Lehrbuch  der  patholog.  Anatomie,"  1885,  il,  531. 

26.  "  Jahresbericht  der  k.  k,  Krankenanstalt  Rudolf-Stiftung,"  1883,  383. 

27.  Hiller,  Monatshefte  f.  prakt.  Demiatologie,  1882,  i,  97  fif. 

28.  Weichselbaum,  "  Bericht  d.  Rudolfspitals  in  Wien,"  1883,  p.  383. 

29.  Zavadski   and   Luxembourg,    Gaz.  Lekaroka,    1893,   vol.  xiil,  p.   1233, 
et  seq. 

30.  Tullio,  "  Contributo  alio  Studio  delle   Lesioni  Funzionale  Gastriche,  per 
Sifilide  edei  coro  Magri  curative,"  Policlijiica,  xv,  Giugni,  1894. 

31.  Bittner,  Centralbl.  f.  allge7n.  Pathologie,  Bd.  V,  1894,  S.  175;  also  Prag. 
med.  Wochenschr.,  1893,  No.  48. 

32.  Chiari,  "International.  Beitrag  z.  Wissenschaft :   Medicin,"  Rudolf  Vir- 
chow,  gewidmet,  1891,  Bd.  11. 


CHAPTER  VI. 

BENIGN  TUMORS  OF  THE  STOMACH. 

JMyomata. — Fibromata. — Lipouiata. — Polypi. — Myxoniata. — 

Papillomata. — Lyviphadeiioviata. — Peduiiailate 

Tumors. — Foreign  Bodies. — GastrolitJis. 

The  stomach  may  be  the  seat  of  a  great  diversity  of  tumors. 
A  neoplasm  that  can  be  determined  by  palpation,  however,  is,  as  a 
rule,  a  carcinoma.  Benign  tumors  are  very  rare,  and  their  clinical 
history  does  not  present  any  great  interest.  But  occasionally  they 
may  become  the  cause  of  errors  in  diagnosis.  This  reason  obliges 
us  to  say  a  few  words  about  them,  as  well  as  of  other  foreign  bodies 
and  gastroliths  which  are  liable  to  occur  in  the  stomach. 

IMyomata,  lipomata,  papillomata,  and  h'mphadenomata  have  been 
found  in  the  stomach. 

In  acute  toxic  gastritis  caused  b\'  the  ingestion  of  corrosive 
sublimate,  calcareous  masses  may  develop  in  the  depths  of  the 
mucous  membrane.  In  comparing  simple  chronic  gastritis  with 
gastric  tuberculosis,  we  have  shown  that  in  the  former  of  these 
diseases  the  glands  were  capable  of  undergoing  a  cystic  degenera- 
tion more  or  less  pronounced.  Aneurysms  of  vessels  in  the  walls 
of  the  stomach  have  also  been  described. 

Polypi. — Papillomata  arising  from  the  mucous  membrane  some- 
times form  very  well  developed  villosities  in  the  pyloric  region. 
In  their  interior  one  finds  a  very  fine  fibrillous  network,  formed 
by  the  prolongations  of  branched  cells;  their  surface  is  covered 
with  cylindrical  epithelium. 

Polypi  may  develop  from  myomata,  lipomata,  fibromata,  and 
papillomata.  The\"  vary  in  size  from  that  of  a  pea  to  that  of  a 
walnut.  They  may  be  pedunculated  or  attached  by  broad  bases. 
The  term  polyp  is  only  descriptive,  and  not  so  important,  anatomic- 
ally, as  the  terms  for  other  gastric  neoplasms.  In  the  structure  of 
polypi  at  times  the  connective  tissue,  at  others  the  glandular 
element,  predominates.  They  might,  therefore,  be  classed  logically 
among  the  fibromata  and  adenomata.     They  may  present  smooth, 

565 


566  BENIGN   TUMORS    OF   THE    STOMACH. 

warty,  or  villous  surfaces,  the  latter  resembling  the  surface  of  a 
raspberry  or  at  times  of  cauliflower. 

Villous  growths  presenting  warty  surfaces  and  a  papillomatous 
structure  should  be  logically  classed  among  the  fibromata  ;  they  are 
covered  by  a  single  layer  of  cylindrical  cells. 

Mucous  Polypi. — Cornil  {Gaz.  des  Hopitaux,  1864,  No.  20)  has 
brought  to  light  two  cases  of  mucous  polypi  which  had  not  mani- 
fested any  symptoms  during  life.  In  one  of  these  cases  the  red, 
mammillated,  in  places  slate-colored,  stomach,  presented  eight  vege- 
tations, from  the  size  of  a  grain  of  wheat  to  that  of  a  bean,  which 
had  their  seat  in  the  vicinity  of  the  pylorus.  These  vegetations 
were  soft,  rosy,  and  injected  with  blood;  their  surface  was  irregu- 
larly mammillated,  and  they  were  formed  exclusively  at  the  expense 
of  the  mucous  membrane.  In  the  other  case  there  existed  only 
one  pedunculated  polypus,  rounded  like  a  cauliflower,  and  as  large 
as  a  hazelnut.  This  tumor,  formed  at  the  expense  of  the  mucous 
membrane  and  of  the  submucosa,  was  very  vascular  at  its  center. 
Lambl  (Prag.  Bcobaditnngen  ans  devi  Franz  Josepli  Kinderspital, 
i860,  p.  376)  has  described  a  tumor  as  large  as  a  pigeon's  &^g, 
extending  three  cm.  along  the  fundus  of  the  stomach,  and  covered 
by  the  mucous  membrane,  which  had  become  thin  ;  no  sign  had 
revealed  its  existence  during  life.  Debove  found  a  mucous  polypus 
by  means  of  the  tube,  in  a  patient  suffering  from  nervous  dyspepsia. 

Rokitansky  attributed  the  formation  of  these  tumors  to  chronic 
gastritis;  they  would  thus  develop  around  the  glands  of  the  papillae 
in  unusual  numbers  and  sizes.  Wilson  Fox  also  admits  the  part 
played  by  inflammation  in  the  genesis  of  these  polypi.  Canus 
Govignon  ("  Polypes  de  I'Estomac,"  These  Paris,  1883)  attributes  a 
certain  influence  to  alcoholism.  These  polypi,  whatever  may  be 
their  structure,  are  somewhat  rare.  The  first  case  was  pointed  out 
by  Cruveilhier  ("Atlas  de  I'Anatomie,"  xxx  livraison.  Fig.  2,  p.  2)  ; 
the  stomach,  the  drawing  of  which  he  gives,  contained  ten  pedun- 
culate excrescences,  one  of  which  obliterated  the  pylorus.  Andral 
{Cliniqiie  Medicale,  tome  1 1)  in  one  case  discovered  laminated 
structures  analogous  to  the  mucosa  of  ruminants.  Ripault  (1833), 
Mercier  (1887),  Castilhes  (1843),  Barth  (1S45),  Richard  (1846), 
Leudet  (1847),  Barth  (1849),  have  reported  a  certain  number  of 
cases  of  the  same  character.  Ebstein  {Arch.  p.  Anat.  n.  Physiol., 
1864)  has  collected  all  these  observations,  and  has  added  14  cases 
which   he   had  himself  obtained   from   600   autopsies.     Of  the  24 


POLYPUS,    LIPOMA,    AND    MYOMA    OF    THE    STOMACH.  567 

cases  thus  collected,  15  occurred  in  men  and  eight  in  women;  in 
one  case  the  sex  of  the  patient  is  not  mentioned.  The  frequency 
of  these  tumors  increases  after  forty  years ;  in  half  the  cases  they 
are  isolated;  in  one  case  there  were  50  of  them,  and  in  two  cases 
there  was  a  number  varying  from  150  to  200.  Their  form  is 
variable  :  they  are  rounded,  club-shaped,  cylindrical,  ramified ; 
their  color  depends  on  their  vascularization ;  frequently  they  are 
pigmented.  The  mucous  membrane  which  covers  them  is  some- 
times entirely  smooth,  sometimes  villous,  or  thickened  ;  they  are 
usually  located  at  the  pylorus,  and  their  size  is  in  inverse  ratio  to 
their  number. 

Lipoma  (Murray,  "  Fatty  Tumor  in  Wall  of  the  Stomach," 
Patliol.  Tr.,  vol.  xi,  1 890). — The  lipoma  is  also  very  rare.  Starting 
from  the  submucosa,  it  sometimes  makes  a  projection  toward  the 
gastric  cavity,  pushing  back  the  mucous  membrane  which  continues 
to  cover  it,  but  grows  thinner  in  proportion  as  the  tumor  increases  ; 
sometimes  it  pushes  aside  the  muscular  fibers  and  succeeds  in  mak- 
ing a  hernia  under  the  serosa.  A  large  tumor  of  this  kind  might 
cause  digestive  troubles  by  the  dragging  of  its  weight  on  the  wall 
of  the  stomach,  but  the  rareness  of  these  cases  interferes  with  an 
exact  knowledge  and  description  of  their  symptoms.  Orth  has 
observed  lipomata  growing  from  the  serosa  in  a  pendulous  manner 
[loc.  cit.,  S.  717). 

Myoma. — The  myoma  develops  in  the  interior  of  the  muscu- 
lar layer,  gradually  projects  under  the  mucous  membrane,  and 
occasionally  ends  by  forming  polypi, — sometimes  isolated,  some- 
times in  numbers.  These  tumors  do  not  differ  in  a  histological  point 
of  view  from  those  which  may  be  found,  for  example,  in  the  uterus, 
but  their  size  rarely  exceeds  that  of  a  pea  or  a  cherry.  Their 
development  is  not  accompanied  by' any  symptoms,  and  they  are 
rarely  discovered  except  at  the  autopsy.  (Myoma,  see  Virchow— 
Onkol,  III,  126.) 

Symptoms. — The  symptomatology  of  these  tumors  is  variable. 
Sometimes  they  become  ulcerated,  and  Rondeau  {Presse  med.  Beige., 
No.  18,  188 1)  has  pointed  out  a  case  where  their  presence  was  re- 
vealed by  serious  hemorrhages  ;  naturally,  the  observer  was  not  able 
to  diagnose  the  cause  of  this  hematemesis.  At  other  times,  as  in 
the  case  of  Cruveilhier's  patient,  the  tumor  may  obstruct  the  pylorus 
and  cause  a  dilatation  of  the  organ.     Bernabes  {Rhnsta  Clinica  di 


568  BENIGN   TUMORS    OF    THE    STOMACH. 

Bologna,  Juillet  et  Auot,  1882)  had,  in  this  wa}%  the  opportunity  of 
observing  a  woman  seventy  years  old  who,  for  a  long  time,  had 
vomited  a  few  hours  after  meals,  and  experienced  sharp  epigastric 
pains,  in  the  absence  of  characteristic  symptoms.  At  the  autopsy 
there  was  found  a  polypus  of  six  or  eight  cm.  implanted  on  the 
anterior  surface  of  the  stomach,  five  cm.  from  the  pylorus.  Five 
other  smaller  poh-pi  were  scattered  on  the  pyloric  antrum  and  along 
the  greater  curvature  (Bruman,  lli.  de  Paris,  1883  ;  Breissaud, 
Arch.  Gen.  de  Med.,  1885;  ]\Iarfan,  Th.  de  Paris,  1887;  Alenetrier, 
Ai'ch.  de  P/ivs.,  15.  Fevrier,  1888). 

Lymphadenoma. — The  stomach  may  also  be  the  seat  of 
lymphoid  tumors.  These  likewise  constitute  a  pathological  rarity. 
Pitt  ("  Pathol.  Trans.,"  vol.  xi,  1890)  has  reported  one  case,  and  states 
that  he  has  been  unable  to  find  more  than  17  in  the  literature  on 
the  subject.  The  patient  had  succumbed  to  phenomena  which  were 
all  attributed  to  a  tumor  of  the  lungs  and  to  an  empyema  of  the 
left  pleura.  Soft  nodules  were  scattered  over  the  stomach  and  the 
intestines  which  had  perforated  the  mucous  membrane,  or  had 
made  greater  or  lesser  projections  at  its  surface ;  histologically, 
all  the  characteristics  of  lymphadenoma  were  exhibited.  The 
spleen,  the  mesenteric,  and  the  bronchial  ganglia  were  invaded  ;  the 
liver  and  the  kidneys  were  not  affected,  however.  The  neoplasm, 
develops  in  the  mucous  membrane  and  the  submucosa,  and  forms 
tumors  projecting  into  the  cavity.  On  the  other  hand,  at  times  the 
serosa  is  first  attacked.  The  muscular  stratum  then  becomes 
more  or  less  affected  by  distention,  and  a  dilatation  of  the  organ 
becomes  evident.  In  other  cases  the  tumors  which  project  into 
the  gastric  cavity  become  ulcerated,  and  the  patient  succumbs 
to  a  hematemesis,  as  in  Reimer's  observation  {D.  Arcli.  f.  klin. 
Med.,  Bd.  xxxiii,  p.  632,  1879).  To  these  phenomena  are  always 
added  a  diarrhea  of  varying  seriousness  ;  but  when  the  tumors 
remain  limited  to  the  stomach,  health  may  be  little  affected 
by  it.  Anatomically,  one  finds  around  the  base  of  the  tumor  a 
hardening  of  the  mucous  membrane ;  the  glands  affected  are  in 
fatty  degeneration,  while  at  their  periphery  there  exists  a  char- 
acteristic reticulated  tissue.  The  degenerated  glands  finally  dis- 
appear, and  there  remains  nothing  more  than  the  reticulated  tissue 
of  the  tumor. 

Pedunculated  adenomata,  attaining  the  size  of  an  apple,  have 


CYSTS,    FOREIGN    BODIES,  569 

been  observed,  which  were  composed  exclusively  of  tortuous, 
irregularly  dilated  gland  tubules.  Tumors  may  occur  in  the 
stomach  as  well  as  in  the  intestines,  which  anatomically  and 
clinically  must  be  considered  cancers,  and  having  a  pronounced 
glandular  structure  are  designated  as  destructive  or  malignant 
adenomata  or  adenocarcinoniata.  The  case  reported  by  Pitt  {loc. 
cit.)  is  suggestive  of  this  type.  They  have  been  considered  under 
the  malignant  tumors. 

Cysts. — Retention  cysts  of  the  gastric  glands  occur  in  "  gastritis 
polyposa  "  and  polypoid  hypertrophy.  Ruysch  ("  Adversaria  Ana," 
torn.  Ill,  p.  I,  Dec,  1732)  described  a  gastric  dermoid  cyst  containing 
hair.  Engel-Reimers  {D.  Arcli.  /.  klin.  Med.,  xxiii,  p.  632,  1879) 
describe  a  multilocular  lymphangioma  occurring  in  the  outer 
gastric  wall  beneath  a  chronic  ulcer  of  the  lesser  curvature.  This 
cyst  contained  a  milky  liquid,  produced  by  stasis  of  lymph  in  con- 
sequence of  occlusion  through  inflammatory  processes  in  the 
vicinity  of  the  ulcer.  Albers  ("  Erlauterungen,"  iv,  p.  151)  men- 
tions a  cyst  2y^  inches  long  found  on  the  lesser  curvature  in  a 
child. 

Foreign  Bodies.  —  Foreign  bodies  are,  in  certain  cases, 
capable  of  imitating  a  tumor,  both  by  the  subjective  symptoms 
which  they  cause,  and  by  the  deception  to  which  they  give  rise 
on  palpation.  A  patient  of  Baillarger's  {Union  Med.,  No.  48,  1874) 
had  kept  in  his  gastric  cavity  for  six  years  a  zinc  fork  ;  an  epileptic, 
cited  by  Foville  {Gaz.  liebd.  de  Med.  et  de  Chir.,  No.  18,  1874),  had 
swallowed  28  dominoes  ;  an  ecclesiastical  patient  thus  preserved 
his  rosary  in  his  stomach  for  a  time.  Labbe  [de  l'  Acad.  des. 
Sciences,  21.  Avril,  1866)  extracted  a  fork  by  gastrotomy.  A  sailor 
("  Med.  Chir.  Transact.,"  vol.  xii,  p.  72),  cited  by  Ewald,  in  imita- 
tion of  a  juggler  swallowed  35  small  knives,  and  only  succumbed 
a  long  time  afterward  to  digestive  troubles;  there  were  found,  at 
the  autopsy,  32  blades,  more  or  less  corroded,  30  in  the  stomach 
and  two  in  the  intestines.  It  is  unlikely,  however,  that  such 
objects  as  these  could  produce  the  signs  of  tumors. 

Schonborn  {Berl.  klin.  Woclienschr.,  No.  17,  1883,  und  Arch.f.  klin. 
Chiriirgie,  Bd.  xxrx,  p.  609,  1883)  has  reported  an  observation  in 
which  a  gastrolitJi  (movable  tumor)  was  discovered  in  a  girl  fifteen 
years  old,  occupying  the  left  half  of  the  abdomen,  it  was  easily 
pushed  back  under  the  left  edge  of  the  ribs,  and  very  painful,  both 
spontaneously  and  on  palpation.    The  patient  grew  thin,  would  not 


570  BENIGN   TUMORS    OF   THE    STOMACH. 

tolerate  any  food,  and  her  state  became  so  serious  that  it  was 
decided  to  perform  a  laparotomy,  after  having  hesitated  for  a  long 
time  between  the  diagnosis  of  a  movable  kidney  and  that  of 
movable  spleen. 

The  opening  being  made,  the  stomach  was  found  distended ;  it  was 
cut  into,  and  a  mass  of  281  gm.  was  found,  formed  by  a  network  of 
short  hairs,  and  molded  to  the  form  of  the  gastric  cavity.  The  patient 
then  confessed  that  four  years  before  she  had  swallowed  the  hair  in 
order  to  "  make  her  voice  clear."  After  this  case,  Schonborn  made 
a  careful  collection  of  the  known  cases,  and  found  seven  of  them,  the 
oldest  of  which  dates  back  to  1777-  These  cases  include  six  women 
and  one  boy  ;  none  were  insane.  All  these  subjects  had  died  ;  some 
from  peritonitis  through  perforation,  others  from  uncontrollable 
vomiting.  One  case  ended  in  hematemesis,  and  Russel  {Med.  Times 
and  Gazette,  June  16,  1869),  who  published  it,  reports  that  the 
tumor  weighed  four  pounds,  seven  ounces,  was  12  inches  long, 
five  inches  broad,  and  four  inches  thick.  Never  before  had  there 
been  digestive  troubles,  and  it  had  been  supposed  that  it  was  a 
tumor  of  the  spleen.  In  the  observation  of  Inmann  {Med.  Times 
and  Gazette,  July  3,  1869),  the  mass  of  hair  was  equally  large. 
Best  {Brit.  Med.  Jonr.,  Dec.  ii,  1869)  reported  a  case  of  a  woman 
thirty  years  old  who,  for  sixteen  years,  had  complained  of  pains  after 
meals,  and  had  frequent  vomitings,  occasionally  streaked  with  blood. 
For  six  years  the  pains  had  been  almost  intolerable,  and  hindered 
the  patient  from  giving  herself  to  any  occupation.  At  the  epigas- 
trium a  movable  tumor  was  discovered,  not  sensitive  to  pressure, 
smooth,  hard,  extending  from  the  right  hypochondriac  region  to 
the  left  of  the  umbilicus,  the  prolonged  palpation  of  which  caused 
emesis.  Peritonitis  from  perforation  ended  the  case.  The  stomach 
and  the  esophagus  were  filled  with  a  quantity  of  hairs,  some  of 
which  were  from  10  to  12  inches  long,  and  which  all  together 
weighed  30  ounces.  The  patient  had  acquired  a  habit  of  swallowing 
her  hair  fifteen  years  before.  Since  Schonborn's  notice,  Kooyker 
{Zeitschriftf.  klin.  Med.,  xiv,  p.  203,  1888,  also  Weekbl.  v.  d.  Nederl., 
Tydscli  V.  Geneesk,  December,  1887)  has  reported  the  case  of  an  indi- 
vidual fifty-two  years  old  who,  after  having  presented  phenomena 
of  cachexia,  with  hematemesis,  succumbed  at  the  end  of  three 
years  of  sickness.  During  life  a  tumor  the  size  of  a  small  apple 
had  been  felt  at  the  epigastrium  ;  and  displacement  of  the  spleen, 
a  floating  kidney,  a  cancer  of  the  stomach,  and  a  cancer  of  the  colon 


GASTROLITHS PHYTOBEZOAR.  5/1 

were  suspected,  one  after  the  other.  At  the  autopsy  a  renal- 
shaped  foreign  body  was  found,  i8  by  8  cm.,  weighing  885  gm. ; 
two  other  masses  were  also  discovered,  the  size  of  a  hen's  egg.  On 
examination  with  the  microscope,  these  bodies  showed  some  grains 
of  starchy  matter  and  some  vegetable  cells,  some  of  which  contained 
chlorophyl,  but  no  trace  of  animal  substances.  This  case  is  analo- 
gous to  that  of  Capelle's  {^Joiir.  de  Med.  de  Briixelles,  Fevr.,  1861), 
who  treated  a  woman  forty-three  years  old  for  a  tumor  of  the 
stomach,  who  had  been  ill  for  a  long  time.  There  were  emesis, 
intense  gastric  pains,  and  constipation.  The  tongue  was  white, 
palpitations  frequent,  the  pulse  small  and  weak.  Under  the 
xyphoid  cartilage  was  found  a  hard,  immovable  tumor  as  large  as 
a  pigeon's  egg,  which  disappeared  when  vomitings,  more  violent 
than  others,  had  caused  the  expulsion  of  a  foreign  body  of  nine 
c.c,  half  softened,  and  formed  exclusively  of  vegetable  debris.  The 
patient  recovered.  Lastly,  Bollinger  {Muncliener  ined.  Wocheiischr., 
No.  22,  1891)  published  the  case  of  a  girl  sixteen  years  old  in 
whom  there  existed  a  hairy  tumor  which  caused  death  by  inanition. 
A  malignant  tumor  had  been  suspected,  and  there  was  found  in 
the  stomach  and  in  the  dilated  duodenum,  a  tumor  55  cm.  long  by 
1 1  cm.  broad,  and  28  cm.  in  circumference,  formed  by  500  gm.  of 
hairs,  which  measured  each  about  ten  cm. 

The  presence  of  foreign  bodies  in  the  stomach  may  give  rise  to 
the  following  signs  and  symptoms :  The  organ  dilates,  becomes 
displaced  (Russel);  the  mucous  membrane  atrophies  ;  the  pylorus 
may  become  expanded  through  muscular  efforts  to  pass  out  the 
foreign  body,  which  will  act  as  a  ball  valve  when  expulsion  is 
impossible;  the  peptic  secretions  disappear;  the  erosions  allow 
the  escape  of  blood  in  more  or  less  abundance,  and  the  patients 
usually  succumb  to  a  cachexia,  since  alimentation  in  the  end 
becomes  impossible. 

Therapeutic  measures  are  useless  in  these  cases.  An  explora- 
tory laparotomy  is  the  only  rational  procedure. 

Erlach  removed  a  myoma  from  the  stomach  weighing  5400  gm. 
{Centralbl.  f.  allgan.  Patholog.^  Bd.  vi,  1895,  p.  240).  In  the  same 
journal  (vol.  vi,  p.  717)  Hansemann  is  reported  as  having  found 
four  peculiar  tumors  in  the  stomach:  (ij  A  myoma  with  cystic 
degeneration  ;  (2)  a  sarcoma  with  hyaline  degeneration  and  con- 
taining large  calcareous  bodies;  (3)  a  tumor  of  myxomatous 
nature  ;  (4)  a  tumor   composed  of  finely  fibered  connective  tissue, 


572  BENIGN   TUMORS    OF   THE   STOMACH. 

inclosing  hollow  spaces  which  contained  cells  in  a  state  of  fatty- 
degeneration,  simulating  the  cortical  substance  of  the  adrenal 
bodies.  Professor  Julius  Schreiber  reported  a  case  of  phyto- 
bezoar composed  of  the  fibrous  roots  of  a  plant  (Schwarzwurzel) 
which  is  a  popular  remedy  for  all  sorts  of  ailments  in  Germany. 
The  patient  was  a  female  peasant  forty-five  years  old.  The  tumor 
very  much  resembled  a  floating  spleen  or  malignant  neoplasm. 
The  diagnosis  was  correctly  made  and  the  woman  successfully 
operated  upon  by  von  Eiselsberg  {Mittheil.  a.  d.  Grciizgebieten  d. 
Medisin  ii.  d.  Chirurg.,  Bd.  i,  1896,  S.  729). 


CHAPTER  VII. 
MOTOR  INSUFFICIENCY. 

Gastric  Atony  or  Myasthenia. —  Gastrcctasia  {^Dilatation  of 
the  Stojnach). 

There  is  no  uniformity  in  the  classification  of  the  various  forms 
and  degrees  of  abnormal  enlargement  of  the  stomach. 

The  defective  function  in  these  cases  is  not  commensurate  with 
the  size  and  capacity,  but  with  the  tonicity  of  the  peristalsis.  A 
very  large  stomach  (megalogastria)  may  have  a  perfect  motor 
function,  and  a  very  small  stomach  may  have  a  defective  motility. 

Boas  recognizes  a  mechanical  insufficiency  of  the  first  degree, 
which  is  a  m)'asthenia  or  atony  of  the  gastric  muscularis  in  which 
the  ingesta  remain  in  the  stomach  too  long,  but  finally  are 
completely  moved  out  into  the  intestines.  There  is  no  absolute 
retention  of  food,  but  simply  a  delay  in  the  expulsion.  Boas  calls 
the  fully  developed  dilatation  mechanical  insufficiency  of  the  second 
degree. 

Riegel   differentiates  : 

1 .  Simple  atony,  or  instfficiency  of  the  stomach. 

2.  Atonic  or  typical  ectasia,  or  dilatatioii. 

3.  Secondary  ectasia,  or  pyloric  stenosis  zvith  ectasia  {dildtation\ 
Naunyn  speaks   simply  of  motor  insufficiency,  and  Rosenbach 

of  mechanical  stomach  insufficiency.  Schreiber  (Boas,  Archil'  f. 
Verdannngskranklieiten,  Bd.  11,  S.  423),  in  attempting  to  select  a 
designation  which  should  signify  the  most  constantly  present  con- 
dition of  all  these  morbid  states  of  motility,  and  one  which  should 
unite  them  all  around  itself,  reached  and  suggested  the  term  stasis 
stomach  ("  Stauungsmagen  "),  wit*li  permanent  digestion  or  perma- 
nently digesting  stomach.  Besides  being  a  cumbersome  circum- 
locution, the  term  does  not  even  include  all  conditions  of  this  type, 
for  in  Boas'  mechanical  insufficiency  of  the  first  degree,  and  in 
Riegel's  simple  atony — conditions  which  we  are  convinced  really  do 
exist — there  is  certainly  no  permanent  digestion. 

Permanent  digestion  goes  on  in  fully  developed  dilatations  with 

573 


574  MOTOR    INSUFFICIENCY. 

impaired  peristalsis  as  long  as  hydrochloric  acid  and  ferments  are 
secreted.  But  as  there  undoubtedly  are  long-standing  dilatations 
with  complete  achylia  gastrica,  or  loss  of  secretion  (Einhorn),  there 
can  be  no  digestion  in  them.  The  fact  that  the  food  is  over- 
retained  in  them  does  not  imply  that  it  is  digested;  only  in  dilata- 
tions that  show  hydrochloric  acid  and  ferments  can  we  speak  of 
permanent  digestion.  The  efforts  of  Schreiber  to  establish  Reich- 
mann's  chronic  secretion  as  a  complication  of  dilatation  with  re- 
tained food  products  and  permanent  secretion  caused  by  stimula- 
tion of  the  retained  food,  are  very  convincing.  We  shall  speak  of 
the  pathogenesis  of  gastrosuccorrhea,  or  Reichmann's  disease,  under 
the  Nervous  Affections  of  the  Stomach.  It  is  impossible,  however, 
to  invent  a  term  which  shall  comprise  the  important  features  of  all 
types  of  motor  and  mechanical  insufficiency,  and  probably  as  clear 
a  classification  as  any  is  one  based  on  Riegel  and  Boas,  as  follows  : 

1.  Simple  gastric  atony,  or  motor  insufficiency,  or  myasthenia 
without  dilatation. 

2.  Atonic  dilatation  (motor  insufficiency  due  to  relaxation  of 
the  gastric  walls)  without  pyloric  stenosis. 

3.  Secondary  dilatation  (motor  insufficiency  due  to  pyloric 
stenosis). 

It  is  self-evident  that  these  conditions  may  have  widely  different 
causes ;  the  one  common  sign  is  not  the  retention  of  food  nor 
permanent  digestion,  but  the  impaired  motility. 

Etiology. — Two  kinds  of  cases  may  occur  :  either  the  atony  of 
the  gastric  wall  is  not  due  to  a  mechanical  obstacle, — in  this  case 
nothing  will  oppose  the  free  course  of  the  contents,  and  they  will 
only  linger  in  the  stomach  because  the  latter  is  really  incapable  of 
ejecting  them  from  its  cavity  in  proper  time, — or  the  atony  will  be 
due  to  a  pyloric  stenosis;  the  muscular  tonicity  will  have  been 
overcome  by  an  impassable  obstacle,  the  fibers  exhaust  themselves 
in  contending  with  an  excessive  resistance,  and  the  dilatation  may 
then  be  considered  as  following  on  existence  of  the  obstacle.  In 
the  first  case  the  etiology  is  variable,  and  arises  finally  from  a 
defect  in  the  nutrition  of  the  muscular  layer  ;  in  the  other  case  it 
is  purely  mechanical. 

DILATATION  CAUSED  BY  A  MECHANICAL  OBSTACLE. 
Intrinsic  causes  of  opposition  to  the  passage  of  stomach  contents 
into  the  intestines,  and  of  such  a  resistance  to  the  contractions   of 


EXTRINSIC    AND    INTRINSIC    CAUSES    OF    STENOSIS.  575 

the  Stomach  that  it  dilates,  are,  first  of  all,  the  constrictions  of  the 
pylorus.  These  are  generally  the  result  of  anatomical  alterations, 
viz.,  cancer,  cicatrices,  circular  ulcer,  or  muscular  hypertrophy  of 
the  pyloric  sphincter. 

Nauwerk  {loc.  cit?)  was  one  of  the  first  to  draw  attention  to 
hyperplasia  and  hypertrophy  of  the  pyloric  sphincter  as  a  cause 
of  dilatation.  A  spasm  of  the  pylorus,  which  can  be  compared 
to  a  spasm  of  the  sphincter  of  the  anus,  can  just  as  well  deter- 
mine an  occlusion.  This  spasm,  which  has  been  admitted  by 
authors  for  a  long  time,  for  reasons  a  little  theoretical  perhaps, 
has  been  demonstrated  since  gastric  surgery  has  permitted  the 
more  direct  exploration  of  this  organ.  Martin  {ioc.  cit.)  has  reported 
a  case  in  which  a  pylorus  large  enough  to  admit  the  passage  of 
two  fingers  brought  on  a  considerable  dilatation  by  its  spasmodic 
constriction,  consequent  upon  a  circular  ulcer  accompanied  by 
considerable  hyperacidity.  Landerer  [loc.  cit.)  is  said  to  have 
proved  the  existence  of  a  congenital  pyloric  constriction  analogous 
to  the  congenital  mitral  constriction  described  by  some  authors. 
He  collected  ten  such  observations,  and  claimed  that  this  orifice, 
large  enough  during  infancy,  might  undergo  an  arrest  of  develop- 
ment and  remain  very  small,  while  the  stomach  grows  larger 
with  age;  a  serious  dilatation  would  result  from  these  diverging 
effects. 

However,  the  obstacle  need  not  necessarily  have  its  seat  in  the 
tissue  of  the  pylorus  itself  In  the  chapter  on  Benign  Tumors  we 
have  described  the  possibility  of  a  polypus  inserted  in  the  gastric 
cavity  and  capable  of  bringing  about  a  dilatation  by  becoming  fixed, 
more  or  less,  in  the  intestinal  orifice,  and  thus  causing  its  occlusion, 
acting  like  a  ball-valve.  Deiters  (Joe.  cit.)  has  collected,  from  the 
Anatomical-Pathological  Institute,  of  Greifswald,  a  large  number  of 
observations,  in  which  congenital  malformations,  abnormal  foldings, 
diverticulse,  and  atresia  had  provoked  dilatations  by  constricting 
the  intestine  in  the  immediate  vicinity  of  the  pylorus.  An  ana- 
tomical lesion  of  the  duodenum — the  cicatrix  of  an  ulcer,  for 
example — would  produce  the  same  effects  by  diminishing  the 
caliber  of  the  passage. 

The  causes  of  extrinsic  origin  which  have  been  observed  to 
effect  compression  of  the  pylorus  or  duodenum  are  very  numerous. 
Among  these  are  peritoneal  adhesions,  circumscribed  or  not,  the 
results  of  former  inflammations.     Fibrous  bands   issuing-  from  a 


5/6  MOTOR    INSUFFICIENCY. 

gastric  cicatrix  may  so  distort  the  normal  location  of  the  p\'lorus 
(although  not  situated  in  the  pylorus  itself)  as  to  compel  the 
duodenum  to  describe  an  abnormal  course. 

Inflammations  originating  in  the  liver  and  the  pancreas  may 
be  the  starting-point  of  similar  anatomical  modifications.  The 
head  of  the  pancreas,  so  intimately  connected  with  the  duodenum, 
may  become  cystic  or  cancerous,  and  cause  a  duodenal  stenosis 
by  compression,  with  following  dilatation  of  the  stomach.  A  con- 
genital displacement  of  the  duodenum  would  bring  about  the  same 
disorders  (Cechini).  Biliary  concretions,  by  dilating  the  diverti- 
culum of  Vater,  or  by  compressing  the  intestinal  wall,  may  produce 
a  compression  of  the  duodenum  sufficient  to  bring  about  gastric 
dilatation;  Grundzach  has  recently  reported  a  case  of  this  kind. 
Landau  {Joe.  cit^,  Bartels  [loc.  cit.),  Warnek  (Joe.  eit?),  Mueller  {Joe.  cit.), 
Litten  {loc.  eit),  and  other  authors  have  studied  the  relations  of 
dislocation  of  the  right  kidne\'  and  of  gastric  dilatation.  Similar 
studies  have  been  made  in  an  interesting  work  by  Bruhl,  and 
Mathieu  has  also  recently  reported  new  cases  (Societe  Medicale 
d'Hopitaux).  Patients  presenting  this  coincidence  of  movable 
kidney  and  dilatation  of  the  stomach  are  usually  young  girls  or 
women  of  the  working  class,  who  are  in  the  habit  of  fixing  their 
skirts  at  the  level  of  their  hips,  and  lacing  tightly,  causing  an 
external  constriction,  which  is  shown  by  the  presence  of  a  per- 
manent furrow.  Fleiner  {loe.  cit.,  p.  21 1)  gives  a  number  of  graphic 
illustrations  on  these  malformations.  Men  who  wear  a  belt  or  strap 
may  produce  the  same  results.  Lud.  Knapp  ("  Wanderniere  bei 
Frauen,"  Berlin,  1896)  associates  the  frequency  of  floating  kidney 
with  abnormalities  in  the  pelvic  organs  in  women,  causing  constant 
dragging  on  the  kidneys  by  means  of  the  ureters.  The  right 
kidney  may  become  displaced  forward  and  inward,  pressing  upon 
the  fixed,  descending  portion  of  the  duodenum,  which  is  situated 
between  the  hilum  of  the  kidney  and  the  vertebral  column.  Such 
partial  obliteration  of  the  intestine  would  bring  about  a  slower  and 
more  difficult  evacuation  of  the  contents  of  the  stomach.  As  food 
would  remain  much  longer  in  the  stomach,  there  would  result, 
first,  an  increase  of  activity  and  a  slight  hypertrophy;  then,  later, 
a  muscular  relaxation,  distention  of  the  walls,  and  a  dilatation  of 
the  cavitv  of  the  organ.  We  shall  treat  the  effects  of  floating 
kidney  more  fully  in  the  chapter  on  Enteroptosis. 

Ewald  {loc.  cit)  and   Pertick   {loc.  cit.)   have  gathered  together  a 


ATONIC    DILATATION.  5/7 

certain  number  of  cases  in  which  a  hernia  of  the  floating  portion 
of  the  duodenum,  or  of  the  first  part  of  the  jejunum  through  a 
laceration  in  the  mesentery,  or  a  diverticulum  of  these  portions  of 
the  intestine,  has  brought  about  an  impediment  to  the  normal 
course  of  the  ingesta,  and  caused,  in  the  end,  a  gastric  dilatation. 

ATONIC  DILATATION. 

Gastric  atony  is  a  condition  of  reduced  or  lost  tonicity  of  the 
musculature.  It  is  a  state  of  sub-  or  hypotonicity,  also  very  aptly 
designated  as  gastric  myasthenia. 

Dilatations  resulting  from  this  state  which  seem  to  be  primary 
may  be  acute  or  chronic.  The  first  kind,  which  are  very  rare, 
have  for  their  cause  either  a  traumatism  or  a  surgical  intervention 
(laparotomy),  or  else  a  serious  infectious  disease;  Hilton  Fagge 
{loc.  cit}),  Bartels  {loc.  cit.),  Montaya  [loc.  cii.),  and  Lepoil  [loc.  cit) 
have  cited  examples  in  which  typhoid  fever  seems  to  have  played 
the  part  of  the  chief  cause.  In  this  case  the  dilatation  seems  to  be 
due  to  the  loss  of  tonicity  of  the  musculature  of  the  stomach  and 
of  the  abdomen.  In  other  cases  the  origin  of  the  evil  is  an  excess 
of  food,  an  error  committed  so  frequently  by  convalescents  after 
they  have  been  confined  to  one  diet  for  a  long  time. 

Chronic  forms  of  atonic  dilatations  are  dependent  upon  a  great 
number  of  factors.  Those  addicted  to  excessive  indulgence  in  food 
suffer  first  with  distention  of  the  stomach  ;  then,  later,  with  dilata- 
tion. This  phenomenon  is  comparatively  frequent  with  persons  into 
whose  ordinary  diet  enters  a  large  quantity  of  liquids ;  such  is  the  case 
with  excessive  beer  drinkers,  the  beer  acting  not  only  mechanically 
by  its  volume,  but  also  through  the  irritating  and  poisonous  sub- 
stances with  which  it  may  be  adulterated.  Debove  {ioc.  cit.)  has 
drawn  attention  to  the  drawbacks  of  prescribing  milk  in  con- 
siderable quantities,  and  has  cited,  among  others,  a  case  of  circular 
ulcer  cured  by  the  daily  allowance  of  eight  liters  of  milk  ;  but  an 
enormous  dilatation  of  the  stomach  resulted.  In  the  chapter  on 
Acute  Gastritis  we  have  pointed  out  that  overfeeding  produces  a 
certain  amount  of  gastritis.  The  dilatation  is  produced  under  this 
double  influence  of  the  inflammation  and  of  the  distention ;  with- 
out the  addition  of  the  first  of  these  causes,  megalogastria  alone 
would  occur. 

Simple  chronic  gastritis  may  result  in  a  considerable  atrophy  of 
the  muscular  fibers  of  the  stomach,  which  may  lead  to  dilatation  of 


5/8  MOTOR    INSUFFICIENCY. 

the  stomach.  The  same  may  be  said  of  hyperchylia,  provided  that 
it  is  one  of  the  forms  where  a  hyperacid  secretion  causes  a  prolonged 
stasis  of  the  amylaceous  substances  ;  such  cases  have  been  collected 
by  Mathieu  and  Remond,  under  the  name  of  dyspepsia  with  or- 
ganic hyperacidity  and  stasis.  In  other  cases  muscular  atony  is 
the  result  of  a  prolonged  retention  in  the  stomach  of  undigested 
food,  with  fermentation  thereof,  when  hydrochloric  acid  is  absent. 
Drawn  out  by  a  weight  more  or  less  considerable,  and  distended 
by  the  gases  that  are  developed  in  the  putrefying  mass,  the  muscular 
fibers  gradually  lose  their  elasticity.  The  dilatation  found  in  con- 
sumptives, in  chlorosis,  etc.,  is  due  solely  to  chronic  gastritis,  which 
is  caused  by  alterations  in  the  blood,  the  results  of  these  diseases. 
In  diabetes  both  the  chronic  gastritis  and  superabundance  of  food 
co-operate  in  the  alteration  of  the  walls,  and  may  finally  lead  to 
amyloid  and  colloid  degenerations  of  the  muscular  fibers. 

Atony  of  purely  nervous  origin,  concerning  which  the  French 
writers  Germain-See  {loc.  cit.)  and  Mathieu  {loc.  cii)  have  published 
numerous  researches,  is  held  by  them  to  be  a  consequence  of  crises 
appearing  to  indicate  the  successive  and  alternating  intervention  of  a 
particular  state  of  spasm  and  of  atony  of  the  gastro-intestinal  tract. 
These  crises  are  produced  by  an  occasional  and  general  cause, 
such  as  sad  emotions,  mental  shock,  neurasthenia,  etc. 

The  atonic  form  of  dilatation  was  first  recognized,  toward  the  end 
of  the  last  century,  by  John  Peter  Frank  {loc.  cit),  who  separates  it 
distinctly  from  the  forms  caused  by  stenosis.  The  atony  due  to 
neurasthenia  can  be  just  as  well  brought  about  by  lesion  of  the  cen- 
tral or  peripheral  nervous  system,  and  the  dilatation  will  then 
depend  on  a  deep-seated  alteration  either  of  the  central  organs,  or  of 
the  peripheral  nerves.  Bouveret,  Dujardin-Beaumetz,  and  Glenard 
have  represented  general  ptosis  of  the  abdominal  organs  as  the 
expression  of  a  particular  diathesis,  a  condition  of  relaxation  of 
the  tissues  with  smooth  muscular  fibers,  and  have  suggested  that 
there  is  a  dilatation  depending  upon  this  general  state.  The  dila- 
tations resulting  from  nephroptosis  are  included  in  this  class  by 
Glenard,  Debove,  and  Remond.  (These  states  will  be  more  fully 
considered  in  the  chapter  on  Enteroptosis.) 

Pathological  Anatomy. — Having  already  considered  the  patho- 
logical histology  of  the  various  causes  of  dilatation,  viz.,  neoplasms, 
benign  and  malignant  cicatrices,  chronic  interstitial  gastritis,  etc., 
etc.,  the  pathological  anatomy  of  the  dilatation,  per  se,  is  simple. 


PATHOLOGY    OF    DILATATION.  579 

At  the  autopsy  of  a  subject  dead  from  cancer  of  the  pylorus,  for 
instance,  one  finds  the  abdomen  filled  by  a  voluminous  sac,  which 
comes  down  more  or  less  near  the  pubes.  This  sac,  which  repre- 
sents the  stomach  having  lost  all  its  normal  relations,  and  ex- 
cessively dilated,  may  contain  enormous  quantities  of  liquid,  and 
the  ancient  authors,  who  knew  only  the  extreme  cases,  have  cited 
extraordinary  examples  of  this.  (The  history  of  the  subject  is 
given  by  Penzoldt,  "Die  Magenerweiterung,"  Erlangen,  1875.) 
Plempius  {loc.  cit.)  is  said  to  have  seen  a  stomach  that  held  nine 
pints  of  liquid;  Stengel  mentions  a  stomach  containing  12  "mea- 
sures ";  Schurig,  a  stomach  containing  48  liters  ;  Henricus  ab  Herr 
found  a  stomach  which  filled  the  whole  of  the  abdomen.  (Pen- 
zoldt, loc.  cit?)  Portal  (quoted  by  Ewald  and  Pick)  states  that  the 
stomach  of  the  Duke  of  Chausnes,  one  of  the  greatest  "  gour- 
mands "  of  his  time,  had  a  capacity  of  4^  liters. 

The  walls  of  the  gastric  sac  have  become  thin ;  in  general  this 
thinness  is  found  in  all  the  coats,  and  microscopically  one  finds  an 
atrophy  of  the  mucosa;  at  the  same  time,  the  muscularis  is  now 
composed  only  of  isolated  bunches  of  muscular  fibers  separated  by 
the  connective  tissue.  When  the  dilatation  is  caused  by  an  obstruc- 
tion at  the  pylorus,  hypertrophy  of  the  muscular  wall  is,  as  a  rule, 
produced  first;  then  interstitial  sclerosis  comes  on,  little  by  little, 
submerging  the  true  elements,  and  the  final  atony  of  the  wall  is 
due  to  the  disappearance  of  the  contractile  fibers.  An  apparent 
hypertrophy,  through  exaggerated  proliferation  of  the  connective 
tissue,  sometimes  masks  the  actual  atrophy  of  muscle  fibers  in 
these  cases.  The  muscular  hypertrophy  continues  very  long  in 
the  pyloric  region,  where  it  also  attains  its  maximum  point.  The 
increased  resistance  and  thickening  of  the  walls  sometimes  results 
from  ulcer,  and  may  simulate  a  tumor  (Remond). 

A  dilated  stomach  may  present  variable  forms  due  to  the 
action  of  the  special  cause.  If  a  cicatricial  or  scirrhous  constric- 
tion causes  the  cardia  and  the  pylorus  to  approach  each  other,  the 
stomach  will  be  pyriform  ;  but  if  the  same  lesion  has  plowed  a 
transverse  furrow,  more  or  less  deep,  on  the  wall,  a  dilatation  in  the 
shape  of  an  hour-glass  will  be  produced;  but  the  symptoms  do  not 
differ  from  those  caused  by  occlusion  of  the  pylorus. 

Symptomatology. — The  tongue  is,  in  most  cases,  coated  by 
necrobiotic  epithelium,  mucus,  and  retained  food  debris,  the  breath 
frequently  being  very  offensive ;  there   is  generally  a   stomatitis, 


580  MOTOR    INSUFFICIENCY, 

glossitis,    or    gingivitis    present.     We    have    spoken    fully    of   the 
various  states  of  the  tongue  on  page  432. 

State  of  tJie  Appetite. — The  appetite  is  normal  at  the  beginning, 
but  when  the  disease  is  developed  it  may  be  lost,  or  become  con- 
siderably decreased.  Some  patients,  for  instance,  will  not  need 
more  than  one  meal  a  day.  In  other  cases,  since  the  stomach 
merely  plays  the  part  of  a  reservoir  with  no  outlet,  and  the  foods 
being  no  longer  evacuated  from  the  stomach  into  the  intestine, 
digestion  and  absorption  can  not  occur.  In  rare  instances  the 
patients  may  be  tormented  with  hunger,  and  they  are  in  an 
analogous  situation,  so  far  as  effects  are  concerned,  to  that  of 
persons  seized  with  an  impassable  stenosis  of  the  esophagus. 
They  try  to  satisfy  their  appetite,  and,  yielding  to  the  solicitation 
of  hunger,  actually  may  present  bulimic  phenomena.  In  reality  it 
is  not  hard  to  understand  this  difference,  which  depends  practically 
on  the  nature  of  the  obstruction  to  the  course  of  the  foods  ;  ano- 
rexia is  observed  chiefly  in  cancerous  patients  and  those  seized 
with  chronic  gastritis,  while  a  cicatrix  of  a  circular  ulcer  may  have 
obliterated  the  pylorus  without  bringing  about  very  serious  inter- 
ference with  the  special  sensibility  of  the  stomach. 

Pyrosis. — The  regurgitation  of  a  certain  quantity  of  very  acid 
or  alkaline  ingesta  often  accompanies  the  eructations  which  pass 
through  the  cardia,  causing  intense  pyrosis. 

Eructations  and  Gaseous  DiscJiarges. — In  motor  insufficiency  of 
the  first  degree,  the  gastric  heaviness  and  the  distention  give  way 
little  by  little,  and,  if  the  patient  takes  his  meals  at  regular  intervals, 
his  stomach  at  last  empties  itself  and  his  pains  disappear.  But, 
in  motor  insufficiency  of  the  second  degree,  generally  the  distress 
ceases  only  when  more  or  less  copious  emesis  has  relieved  the 
gastric  cavity  of  the  foods  which  have  burdened  it,  sometimes  for 
more  than  twenty-four  hours. 

To  this  feeling  of  fullness  are  added  disgusting  gaseous  dis- 
charges, often  very  fetid.  The  alimentary  contents,  in  fact,  are 
liable  to  set  free,  in  considerable  quantity,  many  different  gases. 
We  have  cited  some  examples  of  these  cases  in  the  chapter  on  the 
Gases  of  the  Stomach,  and  Kuhn  {loc.  cit?j  has  published  an  inter- 
esting study  of  this  subject.  The  principal  gases  are  carbonic  acid, 
hydrogen,  oxygen,  nitrogenhydrogen-sulphid,  and  carbonic  di- 
oxid.  Whenever  there  is  stasis,  their  presence  may  be  verified  by 
directly  extracting  the  gas  from   the   stomach  by  the  tube,  or  by 


PAIN    AND    VOMITING.  58 1 

setting  free  the  gastric  contents  in  a  closed  vessel,  after  having  ex- 
tracted them  artificially.  The  causes  of  this  gaseous  development 
are  supposed  to  be  the  presence  of  fungi  resisting  the  antiseptic 
action  of  the  hydrochloric  acid  even  when  present  in  excess,  the 
fungi  having  been  isolated  and  cultivated.  These  fermentations, 
which  are  very  frequent,  are  modified  by  salicylic  acid  or  sacchar- 
in. Boric  acid,  carbolic  acid,  creosote,  and  chlorin  water  have  no 
effect  except  in  doses  which  are  incompatible  with  their  thera- 
peutic use.  The  great  quantity  of  liquid  contained  in  the  stomach 
facilitates  the  development  of  anaerobic  germs,  giving  rise  to  pro- 
ducts of  fermentation  more  complex  and  perhaps  more  poisonous. 

Pain. — The  pain  of  dilatation  is  not  marked;  the  uncomfortable 
sensations  are  those  of  pressure,  fullness,  and  distention.  Naturally, 
if  cancer  or  ulcer  is  coexistent  with  dilatation,  pain  will  be  a 
prominent  symptom. 

Vomiting. — In  motor  insufficiency  of  the  second  degree,  the 
attacks  of  emesis  are  quite  characteristic.  They  are  not  so  fre- 
quent as  they  are  at  certain  stages  of  the  development  of  cancer 
or  of  ulcer,  and  are  generally  separated  from  each  other  by  a 
variable  but  comparatively  long  time,  and  it  is  rarely  that  they 
occur  at  the  time  of  the  maximum  of  digestion.  The  following 
is  the  course  which  matters  usually  take  :  For  one  or  two  days 
a  patient  has  suffered,  after  each  meal,  from  a  sensation  of  growing 
uneasiness,  and  from  a  feeling  of  weight  at  the  epigastrium,  more 
and  more  painful;  then,  suddenly,  often  toward  the  middle  of  the 
night,  he  is  seized  with  very  abundant  vomitings,  after  which  he  can 
enjoy  a  little  rest. 

The  vomited  material  is  sometimes  composed  of  several  liters 
of  a  mixture  of  solid  food,  drinks,  and  mucus.  The  quantity  of 
vomited  matter  is  a  first-rate  symptom  of  dilatation,  and  allows  it 
to  be  distinguished,  for  instance,  from  simple  displacements  of  the 
stomach.  Chronic  gastritis,  cancer,  etc.,  may  also  give  rise  to 
slight  hemorrhages,  and  in  this  case  the  blood,  very  much  modi- 
fied, remains  a  long  while  in  the  stomach  ;  the  same  phenomenon 
can  be  recognized  in  dilatation. 

Boas  has  pointed  out  that  the  persistent  presence  of  bile  and  of 
pancreatic  fluid,  of  which  the  characteristics  have  been  given,  is  an 
indication  of  stenosis  of  the  duodenum,  and  is  a  valuable  symptom 
of  dilatation  following  on  the  compression  of  this  part  of  the  intes- 
tine by  a  dilated  gall-bladder  or  a  movable  kidney,  for  instance. 


582  MOTOR    INSUFFICIENCY. 

The  vomited  matter  will  have  a  more  offensive  smell  the  longer 
it  has  remained  in  the  stomach.  Later  on  in  the  disease,  when 
the  walls  are  distended,  the  vomiting  comes  on  at  greater  intervals, 
the  odor  of  substances  vomited  becomes  more  revolting,  and 
then  the  emesis  is  rarely  sufficient  to  evacuate  the  stomach,  the 
feeling  of  relief,  which  at  first  followed,  is  no  longer  experienced. 
Sometimes  the  vomitings  cease  after  they  have  been  very  frequent 
— a  grave  sign  of  exhaustion. 

Symptoms  of  mito-intoxication  from  dilatation  have  been  described 
by  Al.  Pick  [Wicn.  klin.  Wochenschr.,  1892,  No.  46),  Boas  {loc.  cit., 
p,  73),  and  J.  Friedenvvald  {Med.  News,  1893,  Dec.  23).  A  most 
exhaustive  account  of  the  anto-intoxication  with  motor  insufficiency 
will  be  found  in  the  works  of  Albu  (Joe.  eit.)  and  Bouveret  {loc.  cit}). 

In  dilatation  through  an  organic  cause,  the  disturbance  of  the 
general  state  will  vary  with  this  cause.  Thus,  it  is  observed  that 
in  cancerous  patients  the  dilatation  is  accompanied  by  the  most 
evident  cachexia.  In  ulcer,  Reichmann's  disease,  and  chronic  gas- 
tritis, it  will  be  coincident  with  an  emaciation  more  or  less  marked, 
but  no  cachexia. 

In  the  case  of  children,  Comby  and  Moncorro  have  attributed 
to  dilatation  caused  by  overfeeding  a  certain  part  of  the  develop- 
ment of  rachitis.  The  latter  author  also  considers  it  to  be  the 
cause  of  certain  convulsions,  of  insomnia,  of  ring-worms,  of  urticaria, 
and  of  bronchitis. 

Constipation. — Constipation  is  frequent  and  obstinate,  and  not 
only  are  the  stools  rare,  but  the  quantity  of  substances  evacuated 
is  also  much  less  than  in  the  normal  state.  This  is  a  very  valuable 
indication,  for  it  shows  the  approximate  amount  of  food  which 
passes  into  the  intestines.  Thus  Kussmaul  had  already  been  able 
to  establish  the  prognosis  of  the  patients  attended  by  him  accord- 
ing as,  in  treating  the  dilatations,  the  normal  course  of  the  food 
substances  was  re-established  or  not.  The  latter  state  indicates  an 
incurable  stenosis  of  the  pylorus.  Putrefactive  diarrhea  may  alter- 
nate with  constipation. 

Gastrorrliexis — (Rupture  of  the  Stomach).^Newmann  {loc.  cit), 
Buist  {loc.  cit),  and  Hofman  have  reported  rupture  of  the  stomach 
and  sudden  extravasation  of  its  contents  into  the  peritoneal  cavity. 
Rupture  may  occur  after  a  very  sudden,  acute  dilatation,  or  in  the 
last  stage  of  one  of  long  standing.  The  tear  generally  occurs  near 
an  old  cicatrix.     A  case  reported  by  Chiari  {loc.  cit)  had  a  cicatrix 


URINE  AND  NERVOUS  PHENOMENA.  583 

near  the  lesser  curvature,  through  which  the  tear  occurred  after 
overindulgence  in  food.  In  a  case  observed  by  Hofmann  {loc.cit.),  in 
which  a  rupture  of  the  lesser  curvature  had  taken  place,  no  other 
cause  but  food  engorgement  was  assigned. 

State  of  the  Urine. — The  quantity  passed  in  twenty-four  hours 
may  be  reduced  to  500  c.c.  Boas  makes  use  of  the  daily  quantity 
for  an  approximate  estimate  of  the  degree  of  dilatation. 

1st  degree.     Quantity  of  urine  in  twenty-four  hours,  1500  to  looo  gm. 
2d.        "  "  "  "  "      1000  to  500      " 

3d        "  "  "  "  "       500  gm.  and  less. 

The  urine  is  generally  alkaline,  the  chlorids  diminished. 

The  urine  is  frequently  modified  in  quantity  and  in  quality.  The 
patients  are  in  a  state  of  chronic  inanition,  and  the  urea  is  therefore 
necessarily  diminished.  The  stomach  absorbs  little  liquid,  as  the 
constant  thirst  by  which  these  patients  are  tormented  testifies  ;  and 
the  dilatation  brings  about  a  deficient  urinary  secretion.  Lastly, 
when  the  dilatation  accompanies  an  excessive  secretion  of  hydro- 
chloric acid,  and  the  latter  is  thrown  out,  either  by  frequent  vomit- 
ings or  by  frequent  lavage,  the  urine  becomes  alkaline.  We  have 
already  sufficiently  developed  this  special  urology  on  page  382. 

Nervous  Phenomena. — Erb  found  increased  galvanic  and  faradic 
irritability  of  all  accessible  motor  nerves  with  the  exception  of  the 
facial.  The  increase  of  the  galvanic  irritability  of  the  nerves  is  a 
more  constant  symptom  than  the  increase  of  faradic  irritability. 
Von  Frankl-Hochwart  found  the  latter  to  be  normal  at  times. 
Trousseau  found  that  tetany  could  be  caused  by  compression  of 
the  main  nerve  trunks  or  of  the  principal  blood-vessels  of  the 
limbs,  so  that  the  arterial  and  venous  circulation  was  impeded. 
When  this  compression  was  kept  up  for  two  or  three  minutes,  the 
tetany  began,  but  would  cease  when  the  pressure  was  relieved. 
Chvostek  discovered  an  increase  of  mechanical  irritability  of  the 
nerves  in  the  extremities  and  also  of  the  facial  nerve  in  particular. 
This  irritability  became  evident  on  tapping  the  nerves  lightly  with 
a  percussion  hammer  or  with  the  finger.  This  mechanical  stimu- 
lation brought  on  rapid  instantaneous  twitchings  in  the  muscles 
supplied  by  those  nerves.  On  passing  over  the  face  from  the  tem- 
poral regions  down  to  the  chin  with  the  finger,  distinct  twitchings 
occurred  in  the  muscles  supplied  by  the  facial  nerve,  because  this 
stroke  of  the  fineer  exerted  an   irritation  on   all  branches  of  that 


584  MOTOR    INSUFFICIENCY. 

nerve  (Fr.  Schultze).  Tetany  of  gastric  origin  has  been  considered 
on  page  362. 

Geiie7'al  State  of  HealtJi. — The  general  state  of  health  is  more 
deeply  influenced  by  the  cause  of  the  dilatation  than  by  the  dila- 
tation itself.  Neurasthenia  often  causes  an  atony  of  the  muscle 
fibers  of  the  stomach,  the  consequences  of  which  can  not  but  have 
a  marked  influence  on  the  nutrition  of  the  patient  and  encourage 
and  develop  in  their  turn  a  secondary  neurasthenia.  Diabetes, 
chlorosis,  and  great  pyrexias,  which  may  have  caused  the  atony, 
provoke  general  disorders  also,  and  it  is  difficult  to  distinguish 
from  among  these  disturbances  that  which  belongs  properly  to 
gastric  atony. 

Cardiopulmonary  Syniptovis. — These  have  been  considered  in  the 
chapter  on  the  Influence  of  Gastric  Diseases  on  Other  Organs, 
where  we  have  dwelt  on  the  effects  of  distention  of  the  gastric  cavity 
by  gases  hindering  considerably  the  functions  of  the  diaphragm  and 
disturbing  the  action  of  the  respiratory  apparatus  and  of  the  circu- 
lation, more  or  less  in  different  cases.  Dyspneic  phenomena,  or 
modifications  in  the  sound  of  the  heart  and  in  the  rhythm  of  the 
pulse,  are  most  frequently  met  with. 

Mattheides  {loc.  cit.)  has  gathered  together  a  number  of  cases  in 
which  he  observed  a  sensation  analogous  to  that  of  globus  hyster- 
icus in  patients  afflicted  with  dilatation.  He  called  attention  to  the 
fact  that  this  sensation  was  aggravated  when  the  stomach  had 
sunk  and  diminished;  on  the  other  hand,  when  it  had  risen,  he 
had  concluded  that  the  displacement  of  the  stomach  so  often 
accompanying  the  dilatation  of  this  organ  was  the  cause  of  this 
sensation  of  globus,  through  the  dragging  which  occurs  on  the 
esophagus.  Schmidt  [loc.  cit?)  is  said  to  have  verified,  by  a  lapar- 
otomy, the  existence  of  these  anatomical  disorders  in  a  patient  who 
had  previously  complained  of  the  sensation  of  globus.  The  con- 
nection between  the  two  is  not  at  all  satisfactorily  proven  nor  even 
significant. 

Percussion  and  Palpation  of  the  Stomach, —  As  Osier  [loc. 
cit)  emphasizes,  the  diagnosis  is  often  possible  by  inspection. 
Percussion  and  palpation  allow  us  to  ascertain  the  limits  of  the 
lower  edge  of  the  greater  curvature,  and  thus  to  appreciate  the 
degree  of  the  ectasia.  The  percussion  should  be  performed  with 
the  patient  standing  up,  and  again  when  lying  on  his  back.  The 
measured  ingestion  of  a  certain  quantity  of  water  will  allow  one 


PERCUSSION    AND    PALPATION    FOR    DILATATION. 


585 


to  estimate  the  atony  of  the  wall,  and  will  at  the  same  time  furnish 
exact  data  on  the  displacement  of  the  lower  edge  of  the  organ, 
which  has  become  heavy.  The  stomach  may  be  distended  by  CO2, 
and  the  colon  by  water,  thus  facilitating  the  differentiation  between 
the  two.  Other  authors  have  proposed  to  perform  the  operation 
inversely,  and  percuss  the  stomach  made  heavy  by  a  certain 
quantity  of  water,  while  the  colon  is  distended  by  gas  (Ewald). 
It  is  true  that  these  precautions  would  make  mistakes  very 
difficult.  Professor  Osier  holds  that  when  the  distended  stomach 
is    outHned    on    the   wall    one    can 

usually  follow  its  delineations  with  "  -^^^^ 

the  eye,  and,  of  course,  much  better 
by  percussion.     In  th.Q  Philadelphia  -'^ 

Medical  Times  for  May,  1891, 
Pepper  reports  a  case  of  dilatation 
caused  by  scirrhus  of  the  pylorus 
in  which  there  was  a  visible  peris- 
talsis, s      j 

The  gaseous  distention  has  also  f 

the  advantage  that  it  allows  the 
distinction  to  be  made  between  true 
dilatation  and  a  simple  displacement  J; 

of  the  organ.  f 

By  palpation  the  splashing  sound  [ 

can  be  investigated.  This  is  easy 
to  perceive  when  the  stomach,  the 
pylorus  of  which  is    constricted,  is  - 

full  of  those  liquid  masses  already        Fig. 
mentioned   in   connection   with   the 
vomiting.     But  when  the  dilatation 

is  not  very  marked,  the  splashing  becomes  less  clear,  and  Debove 
has  recently  shown  that  the  intestines,  when  half  distended  by  gases, 
are  capable,  under  the  influence  of  movements  communicated  by  the 
fingers,  of  producing  a  sound  so  like  that  of  the  gastric  splashing 
as  to  make  the  distinction  very  difficult.  Chomele  {^loc.  cit.)  had 
already  drawn  attention  to  this  cause  of  mistakes,  and  to  that  which 
depends  on  the  presence  of  liquid  and  gas  in  the  large  intestine  : 
"  The  splashing  in  the  stomach,"  says  he,  "  might  be  confounded 
with  a  similar  sound  of  which  the  large  intestine  is  sometimes  the 
seat,  which  can  be  produced  by  the  lateral  movement  of  the  body. 


39- 


Dilatation  of  Stomach. - 
{Eichhorst.) 
Outline  obtained  by  percussion. 


586  MOTOR    INSUFFICIENCY. 

but  still  more  easily  by  the  pressure  of  the  hand  on  the  regions 
occupied  by  the  colon."  It  is  met  with  especially  in  subjects  who 
have  recently  received  an  injection,  and  those  who  have  been 
seized  with  serous  diarrhea.  The  knowledge  of  these  conditions 
and  the  particular  source  of  the  gastric  splashing  sound  are  sufficient 
to  distinguish  it  from  intestinal  splashing.  Jaworski  {loc.  cit.)  has 
reported  four  cases  of  very  audible  splashing  sound  even  when,  on 
introducing  the  probe  into  the  stomach,  he  had  been  unable  to 
withdraw  any  liquid  whatever.  The  author  has  observed  this  fact 
in  a  number  of  cases.     It  is  not,  therefore,  a  reliable  sign. 

For  determining  the  location  of  the  greater  curvature,  Thiebaut 
{loc.  cit.),  of  Nancy,  has  devised  an  instrument  which  consists  of  a 
probe  through  which  slides  a  thread  with  a  leaden  weight.  The  probe 
is  long  enough  to  reach  the  cardia,  and  the  quantity  of  thread  taken 
by  the  leaden  weight  before  it  arrives  at  the  bottom  of  the  stomach 
allows  one  to  measure  the  vertical  dimension  of  the  gastric  cavity. 

We  have  described  the  methods  of  procedure  based  on  the 
employment  of  salol,  oil,  iodid  of  potassium,  etc.  (p.  72),  designed  to 
determine  the  state  of  the  motor  functions  and  of  the  absorption 
of  the  mucous  membrane.  In  dilatation  they  give  information  of 
varying  value,  but  inferior  to  that  furnished  by  exploration  with 
the  sound.  We  have  already  stated  the  signs  by  which  one  can 
recognize  atony  of  a  muscular  wall :  either  presence  of  debris  of  food 
in  the  morning  before  breakfast,  or  the  prolonged  stay  in  the  gastric 
cavit}^  of  a  test-meal.  The  Hemmeter  gastrograph  is  a  graphic 
method  of  obtaining  motor  records  from  the  human  stomach,  and 
the  results  obtained  therewith  are  generally  reliable.  (Plates  iii 
and  IV,  p.  ^6.) 

Test-meals. — The  gastric  cavity  should  be  washed  out  on  the 
evening  of  the  day  before  a  test-meal  is  given.  The  substances 
extracted  by  this  preliminary  lavage  are  sometimes  very  abundant, 
and  having  the  same  composition  as  those  vomited,  generally  be- 
come separated,  when  allowed  to  stand,  in  three  layers  :  an  upper 
one,  frothy  and  turbid  ;  a  middle  one,  liquid  ;  and  a  lower  one,  com- 
posed of  alimentary  detritus  of  all  kinds,  or  simply  of  amylaceous 
substances,  as  occurs  in  the  case  of  patients  suffering  from  hyperacid- 
ity. Organic  ferments  and  sarcins  will  be  discovered,  and  all  the 
series  of  products  which  can,  normally  or  abnormally,  be  contained 
in  the  stomach.  If  the  motor  insufficiency  is  caused  by  malignant 
neoplasm,  the  Oppler-Boas  bacillus  will,  as  a  rule,  be  found  in  this 


DIAGNOSIS    OF    DILATATION.  58/ 

material.  In  the  morning  before  breakfast,  the  gastric  cavity,  which 
has  been  cleansed  the  evening  before,  may  again  contain  the  normal 
products  of  secretion,  or  material  which  is  rich  in  organic  acids. 
The  digestion  of  the  test-meal  will  generally  be  slow,  and,  especially 
in  cases  of  cancer,  it  will  be  impossible  to  detect  free  hydrochloric 
acid.  In  other  patients  a  normal  or  exaggerated  state  of  secretion 
of  hydrochloric  acid  will  be  found.  When  the  normal  HCl  is 
absent  the  filtered  gastric  contents  will  show  excess  of  lactic  and 
butyric  acid.  If  the  motor  insufficiency  is  due  to  alcoholism, 
acetic  acid  will  be  a  prominent  constituent. 

Diagnosis. — Dilatation  or  motor  insufficiency  of  the  second  de- 
gree may  have  to  be  differentiated  from  atony,  or  myasthenia  from 
gastroptosis  and  physiologically  large  stomach  or  megalogastria. 
However,  no  sign,  unless  it  is  in  the  presence  in  notable  quantity 
of  food  in  the  stomach  before  breakfast,  is  pathognomonic.  Bugge 
{loc.  cit.)  recommended  the  following  operation  :  he  determined,  by 
percussion,  the  patient  standing  up,  the  lower  edge  of  the  stomach, 
and  drove  the  needle  of  a  hypodermic  syringe  above  the  discovered 
limit.  If  the  liquid  extracted  was  acid  he  concluded  that  the 
stomach  had  been  reached.  It  is  evident  that  this  procedure  is  not 
without  danger,  and  is  not  even  accurate. 

We  prefer  the  simple  exploration  by  means  of  the  sound,  asso- 
ciated or  not  with  artificial  gaseous  distention  of  the  stomach. 
These  methods,  in  fact,  suffice  to  distinguish  a  dilated  from  a  dis- 
placed stomach,  and  from  a  naturally  large  stomach.  But  if  they 
do  not,  the  method  of  the  author  will  leave  no  room  for  doubt. 
(See  p.  y6) 

Gastroptosis  (displacement  of  the  stomach)  will  be  fully  con- 
sidered in  a  special  chapter  on  that  subject.  The  pylorus  may  be 
displaced,  and  freely  movable  below  the  epigastric  region,  without 
in  reality  causing  any  gastric  disturbance.  By  palpation  and  per- 
cussion the  greater  curvature  of  the  stomach  can  be  made  out  below 
the  umbilicus.  One  might  then  be  very  much  disposed  to  suspect 
a  dilatation,  but  on  setting  free  carbonic  acid  gas  in  the  gastric 
cavity,  one  sees  not  only  the  greater,  but  also  the  smaller  curvature 
outlined  under  the  skin,  and  the  outline  of  the  whole  stomach  can 
be  traced  on  the  abdominal  wall,  following  the  limits  of  the  corre- 
sponding resonant  zone  by  percussion. 

The  points  of  difference  between  a  dilatation  and  atony  are  the 
following :    In   the   morning,  before  food    has   been   ingested,  the 


588  MOTOR    INSUFFICIENXY. 

dilated  stomach  contains  an  accumulation  of  putrefactive  products 
and  food  material,  showing  either  excess  of  lactic  and  fatty  acids 
or,  when  these  are  absent,  abnormal  amounts  of  HCl.  In  atonic 
dilatations  and  in  simple  atony  the  stomach  is,  as  a  rule,  entirely 
empty  in  the  morning, — in  rare  instances  it  may  contain  trifling 
amounts  of  food,  but  not  in  a  state  of  decomposition.  In  atony 
the  bowel  evacuations  are  less  likely  to  be  so  few  in  number  and 
small  in  amount.  In  aton}-  the  total  quantity  of  urine  voided  in 
twenty-four  hours  is  normal  or  only  slightly  reduced.  In  dilatation 
the  amount  of  urine  is  subnormal,  concentrated,  and  contains 
diacetic  acid  and  aceton,  which  are  very  rarely  found  in  atony. 

In  megalogastria  we  are  not  dealing  with  a  diseased  stomach, 
and  hence  a  differentiation  is  unnecessary.  Tetany  occurs  only 
with  dilatation,  but  gastric  vertigo  is  frequent  in  atony.  The  differ- 
entiation between  a  dislocated  and  a  dilated  stomach  is  facilitated 
by  the  clinical  history.  In  a  dislocated  stomach  the  motor  func- 
tion is  frequently  normal,  and  hence  we  find  that  emesis,  if  it  occurs, 
does  not  bring  out  such  very  large  amounts  as  in  dilatation. 
Diuresis  and  thirst  are  normal  in  gastroptosis  ;  in  dilatation  thirst  is 
intense,  but  on  account  of  the  regurgitation  or  vomiting  of  fluids 
diuresis  is  subnormal.  No  matter  where  a  stomach  may  be  located 
within  the  abdomen,  or  how  large  it  may  be,  it  does  not  become 
abnormal  until  the  motor  function  is  interfered  with.  A  Leube 
test-meal  or  our  double  test-meal  (see  p.  iii)  will  instruct  us  con- 
cerning these  points.  (For  methods  to  ascertain  the  location,  size, 
and  capacity  of  the  stomach  see  pages  97  to  104.) 

The  differential  diagnosis  between  gastroptosis  or  prolapsus  of 
the  stomach,  gastrectasia  or  dilatation,  and  megalogastria  or  large 
stomach  (giant  stomach),  can  be  facilitated  by  distending  the 
organ  with  air  or  gas,  but  even  here  the  success  of  inspection,  palpa- 
tion, and  percussion  will  depend  upon  the  thickness  and  resistance 
of  the  external  abdominal  wall.  Where  there  is  very  little  or 
no  emaciation,  it  is  by  no  means  easy  to  palpate  through  the 
abdominal  wall.  Then,  again,  much  gas  escapes  into  the  intestine 
when  the  stomach  is  distended  by  effervescent  mixtures. 

But  by  means  of  the  stomach-shaped  intragastric  rubber  bag, 
which  has  been  described  on  page  jd,  or  by  Einhorn's  electro- 
diaphane  (p.  102),  it  is  possible  to  make  the  differential  diagnosis 
without  much  difficulty.  By  the  Hemmeter  apparatus,  which  was 
originally  designed  to  obtain  records  of  the  gastric  peristalsis,  it  is 


PLATE  X. 


Gastrectasia. 
Transillumination  (electrodiaphany)  of  the  stomach.      The  organ  is  filled  with  600  c  a 
of  water,  and  has  sunk  downward  to  the  left.     The  electric  lamp  has  just  reached 
the    fundus— on   being  pushed   further  the  intensest  part  01  the  transillummation 
would  appear  below  the  umbilicus. 


DIAGNOSIS    OF   THE    CAUSE.  589 

also  possible  to  measure  the  capacity  of  the  stomach  by  determin- 
ing the  amount  of  air  required  to  distend  it  within  the  stomach 
(see  p.  loi  on  this  subject).  An  intragastric  rubber  balloon  was 
first  used  for  this  purpose  by  Schreiber,  of  Konigsberg.  This  will 
at  once  enable  one  to  diagnose  a  dilated  stomach  from  one  which 
has  prolapsed  but  retained  its  normal  capacity.  Einhorn's  di- 
aphane  is  a  practical  method  for  demonstrating  these  two  condi- 
tions to  the  eye.  The  Roentgen  rays  are  also  available  for  the  same 
purpose,  as  demonstrated  by  the  author  (Hemmeter,  "Photography 
of  the  Human  Stomach  by  the  Roentgen  Rays,"  Boston  Medical 
and  Surgical  Journal ,  1 896).  The  greater  curvature  may  be  outlined 
by  photographing  a  metallic  spiral  electrode  that  has  been  intro- 
duced and  made  to  apply  itself  along  the  greater  curvature,  accord- 
ing to  suggestions  first  made  by  Wegele  ;  or  the  stomach  may  be 
photographed  by  our  method,  which  consists  in  distending  the 
stomach  by  an  intragastric  stomach-shaped  bag,  the  inner  surface 
of  which  has  been  previously  coated  by  a  deposit  of  plumbic 
acetate  or  nitrate  of  silver,  which  is  poured  into  the  bag  in  a 
saturated  solution  and  allowed  to  dry  on  the  inside.  The  bag  is 
then  introduced  and  distended  by  air,  filling  out  exactly  the  entire 
stomach.  The  thin  coating  of  plumbic  acetate  cuts  off  the 
Roentgen  rays  sufficiently  to  obtain  a  photograph.  This  method 
is  troublesome,  and  can  be  satisfactorily  executed  only  in  hospital 
practice.  For  private  practice  the  Einhorn  electrodiaphane  is 
most  expedient,  as  it  permits  a  diagnosis  to  be  made  by  inspec- 
tion. Debove  and  Remond  ("  Maladies  de  I'Estomac,"  p.  Z'j^ 
state  that  this  method  is  difficult  of  execution,  and  imposes  much 
suffering  upon  the  patient.  From  what  we  have  seen  almost 
weekly  with  Einhorn's  apparatus,  we  differ  emphatically  from 
these  observers,  and  believe  a  further  experience  with  the  apparatus 
will  effect  a  change  in  their  opinion. 

Diagnosis  of  the  Cause. — The  cause  is  more  difficult  to  detect 
than  the  dilatation  itself.  In  this  connection  we  refer  to  what  has 
been  said  in  the  consideration  of  ulcer  carcinoma,  benign  neoplasms, 
etc.,  and  their  respective  diagnosis. 

The  anamnesis,  the  examination  of  the  substances  vomited,  and 
the  results  furnished  by  test-meals  will  provide  the  principal  data. 
The  clinical  history  differs,  in  fact,  considerably,  according  as  one 
finds  a  dilatation  of  cancerous  origin  or  one  caused  by  ulcer  or  gastri- 
tis. The  ingestion  of  poisons  and  their  effects  have  been  considered 
39 


590  MOTOR    INSUFFICIENCY. 

under  Toxic  Gastritis.  The  corrosive  poisons  frequently  effect 
a  cicatricial  contraction  of  the  pylorus.  If  hydrochloric  acid  is 
present  in  normal  or  excessive  quantity,  one  can  eliminate  cancer 
almost  with  certainty,  especially  if  the  substances  vomited  contain, 
at  the  same  time,  bile.  If  the  bile  is  always  wanting  in  the  substances 
vomited,  or  in  the  gastric  contents  either  before  or  after  eating,  one 
will  be  led  to  think  of  constriction  of  the  pylorus ;  the  latter  will 
probably  be  of  cancerous  origin  if  the  hydrochloric  acid  is  wanting 
at  the  same  time. 

The  constant  presence  of  bile  and  of  pancreatic  juice  in  the 
stomach  would  be  a  proof  that  the  dilatation  is  a  consequence  of  a 
stenosis  of  the  duodenum,  which  may  result  from  a  movable  kidney, 
a  fibrous  adhesion,  gall-stones,  pancreatic  neoplasm,  etc. 

The  author  has  devised  a  method  by  which  a  stenosis  of  the 
pylorus  and  of  the  duodenum  can  be  accurately  determined  (Hem- 
meter,  "  Intubation  des  Duodenum,"  Boas,  Archiv  f.  Verdmiungs- 
krankh.,  Bd.  ii,  S.  85.     See  also  this  volume,  p.  54). 

Dr.  F.  Kuhn,  who  belongs  to  Riegel's  school  (Giessen),  has  also 
devised  a  method  for  sounding  the  pylorus,  which  is,  however,  a 
development  of  a  revolving  spiral  sound  first  invented  by  Dr.  F. 
B.  Turck,  of  Chicago.  The  Turck-Kuhn  method  is  very  ingenious 
and  simple,  but  owing  to  the  revolving  of  the  spiral  sound  within 
the  stomach,  it  is  a  hazardous  method  in  cases  where  we  should 
suspect  open  ulcers  or  carcinoma,  since  the  intragastric  revolu- 
tions of  the  sound  can  readily  bruise  or  tear  the  ulcer  or  neoplasm 
and  set  up  hemorrhage  or  lead  to  perforation. 

The  accuracy  of  these  results,  it  is  true,  is  by  no  means  absolute, 
but  in  practice,  in  associating  them  with  other  data  furnished  by 
the  elements  of  the  diagnosis  of  each  gastric  affection,  one  arrives 
at  a  sufficient  approximation. 

Prognosis. — The  evolution  of  motor  insufficiency  varies  accord- 
ing to  the  cause  ;  when  it  is  a  case  of  simple  atony  of  recent 
date,  a  proper  treatment,  of  which  we  shall  speak  again  further  on, 
may  bring  amelioration  rapidly,  and  even  cure.  But  when  it  is  a 
case  of  dilatation  with  atrophy  of  the  muscular  coat,  especially  when 
there  exists  an  impassable  obstacle  at  the  pylorus,  the  cure  is  impos- 
sible, except  sometimes  by  operation.  The  treatment  still  relieves 
the  painful  phenomena,  but  the  inanition  makes  progress  from  day 
to  day,  and  the  patient  succumbs  gradually,  unless  one  of  the  com- 
plications that  we  have  mentioned  appears  and  hastens  the  end. 


MALFORMATIONS    OF    THE    STOMACH.  59I 

Malformations  of  the  Gastric  Cavity. — As  dilatation  is,  in 
reality,  a  deformity  of  the  stomach,  a  certain  number  of  malforma- 
tions and  changes  of  form  may  be  appropriately  considered  in 
this  connection. 

According  to  Debove  and  Remond,  atresia  of  the  gastric  cavity 
results  from  diminution  of  work  by  the  organ,  through  insufficiency 
of  alimentary  contributions.  Inanition  and  constriction  of  the 
esophagus  or  of  the  cardia  will  thus  have  been  the  first  cause  of 
this  atrophy.  In  other  cases  it  is  a  cancerous  infiltration  extend- 
ing over  the  whole  wall,  or  a  chronic  gastritis  with  hypertrophy  of 
the  submucosa  and  of  the  connective  tissue  (linitis  plastica),  or  a 
fibrous,  deforming  peritonitis,  which  will  have  played  the  same  part. 
The  caliber  of  the  stomach  thus  narrowed  sometimes  does  not 
exceed  that  of  the  intestine.  This  condition  we  have  referred  to  in 
the  chapter  on  Hypertrophic  Gastritis.  When  the  upper  digestive 
paths  are  open,  attacks  of  emesis  occur  which  appear  as  soon 
as  the  quantity  of  food  exceeds  the  very  small  volume  of  the 
stomach,  the  small  caliber  becoming  still  more  evident  when  one 
comes  to  distending  it  with  carbonic  acid,  or  expanding  it  with 
the  intragastric  rubber  bag.  If  stenosis  of  the  esophagus  or 
of  the  cardia  exists,  the  passage  of  the  probe  becomes  impossible, 
and  the  symptoms  of  these  constrictions  assume  enough  im- 
portance to  obscure  entirely  those  which  might  be  furnished  by 
the  state  of  the  stomach. 

The  Hour-glass  Stomach. — This  type  of  deformed  stomach  has 
been  frequently  reported.  We  quote  the  following  cases  from 
Remond  {loc.  cit.).  Stoker  {loc.  cit.)  has  published  one  case  where 
the  stomach,  divided  into  two  parts  by  a  congenital  furrow,  had 
never,  during  life,  presented  any  functional  disturbance.  lago 
{loc.  cit.)  has  related  the  story  of  a  patient  who  succumbed  when 
forty-two  years  old,  after  having  presented  for  ten  months  uncon- 
trollable vomitings  ;  on  the  examination  of  the  abdomen,  there  was 
found  underneath  the  liver  a  soft  tumor,  which  had  been  taken  for 
the  right  kidney,  displaced  ;  there  existed  no  tumor  at  the  level  of 
the  pylorus  ;  emesis  took  place  without  pain,  and  was  not  pre- 
ceded by  regurgitation;  there  was  no  cachexia  to  be  found.  At 
the  autopsy  there  was  found  a  stomach  presenting  two  dilated  sacs, 
which  communicated  by  a  closed  narrow  passage  situated  about  the 
middle  of  the  organ  ;  the  index  finger  could  not  pass  this  constriction. 
The  cicatrices  which  had  produced  this  deformity  must  have  been 


592  MOTOR    INSUFFICIENCY. 

caused  by  a  former  disease,  which  appeared  at  the  age  of  thirty  and 
was  characterized  by  hematemesis  and  acute  pains.  A  patient  fifty 
years  old,  observed  by  Luigi  Mazotti  {loc.  cit.),  experienced  such 
intense  pains  after  meals  that  she  used  to  squirm  on  her  bed,  and 
only  found  relief  after  having  vomited  everything  that  she  had  just 
taken.  At  the  autopsy  the  stomach  was  found  divided  into  two 
parts,  the  upper  one  vertical,  the  lower  one  directed  horizontally 
toward  the  right  side  ;  a  narrow  passage  was  situated  between  the 
two  parts.  The  lower  portion  of  the  stomach  had  made  a  com- 
plete circle,  and  the  contracted  point  was  exactly  the  center  around 
which  this  rotation  had  occurred.  The  upper  part  of  the  stomach 
was  distended  by  gases  ;  the  lower  one  was  empty  and  joined  to  the 
abdominal  wall  by  adhesions.  When  the  viscus  had  been  replaced 
in  its  normal  position,  it  was  found  that  neither  the  orifices  nor  the 
wall  presented  any  modification,  and  it  was  impossible  to  discover 
the  cause  of  this  displacement.  In  another  case,  Chiari  (Joe.  cit.) 
suspected  a  cancerous  constriction  of  the  pylorus  in  a  patient  who, 
in  reality,  had  an  intussusception  of  the  stomach  into  the  duo- 
denum. Fleiner  {loc.  cit.)  has  described  and  pictured  a  number  of 
gastric  deformities  caused  by  tight  lacing  {ScJinurmageii).  In  some 
of  his  types  the  pylorus  and  cardia  are  so  compressed  and  brought 
near  to  each  other  by  the  lacing  as  to  be  almost  in  juxtaposition. 

Further  particulars  concerning  similar  cases  can  be  found  in  the 
recent  memoirs  of  Bauermeister  {loc.  cii.)  and  Saundby  {loc.  cit)  and 
in  the  theses  of  Kern  (Inaug.-Dissert.,  Berlin,  1881)  Chiari  {Wien. 
med.  Wochenschr.,  No.  42,  1890),  Bauermeister  (Inaug.-Dissert., 
Halle,  1790).  Von  Hacker,  in  his  monograph  ("  Magenoperationen," 
etc.,  published  by  Braumiiller,  Vienna),  gives  a  number  of  illustra- 
tions of  stomachs  divided  into  three  parts  by  cicatrices  or  adhe- 
sions. {TWge.v,Virchow's  Ai'chiv,  Bd.,  cxxxiii.  See  Bibliography  at 
end  of  this  chapter.) 

Treatment  of  Motor  Insufficiency  of  the  First  Degree  {Gas- 
tric Atony  or  Myastlienia). — Prophylaxis. — The  muscularis  of  the 
digestive  organs  may  be  weak  by  inheritance.  Chlorosis,  anemia, 
tuberculosis  and  cholelithiasis,  exhausting  hemorrhages,  infectious 
diseases,  typhoid,  malaria,  diphtheria,  influenza,  may  bring  on  myas- 
thenia ;  and  frequent  and  rapidly  consecutive  births  may,  by  causing 
increase  of  space  in  the  abdominal  cavity  and  loss  of  tone  to  the 
abdominal  muscles,  lead  up  to  gastric  atony.  Bad  chewing,  hasty 
eating  and  deglutition,  and  defective  teeth  predispose  to  atony.    The 


DIETETIC    TREATMENT    OF    GASTRIC    ATONY.  593 

treatment  in  all  cases  must  seek  and  adapt  itself  to  removal  of  the 
cause.  Anemia  must  be  treated  by  proper  food,  peptonate  of  iron, 
extract  of  bone  marrow,  and  arsenic.  In  women  with  gastroptosis 
and  atony,  the  abdominal  muscles  must  be  strengthened  and  sup- 
ported by  proper  bandages.  The  treatment  proper  includes  diet, 
hydropathic  and  electric  procedures,  massage,  and  medicines. 

Diet. — Patients  with  gastric  atony  must  eat  frequently,  but  very 
little  at  a  time.  As  water  is  not  absorbed  from  the  stomach,  the 
quantity  of  liquids  must  not  exceed  one  to  l^i  quarts  in  twenty- 
four  hours,  including  all  drinks,  coffee,  soups,  etc.  When  there  is  a 
craving  for  more  liquid  than  this,  it  should  be  introduced  by  enema. 

Our  experience  with  the  frequent  and  persistent  administration 
of  milk  as  observed  in  milk  cure  sanitariums  in  Germany  is  dis- 
couraging. We  believe  this  treatment  to  be  a  useless  dietetic 
experiment  in  gastric  atony. 

The  special  diet  must  be  selected  according  to  the  state  of  the 
gastric  secretions.  If  there  is  hyperacidity,  a  vigorous  beef  and 
mutton  diet,  with  limited  carbohydrates,  hard-  and  soft-boiled  eggs, 
ham,  tongue,  oysters,  duck,  and  deer  in  every  form  is  recommended; 
of  vegetables,  we  allow  carrots,  spinach,  soft-boiled  turnips,  beans, 
peas,  cauliflower.  Potato,  macaroni,  rice,  and  farina  gruel  are  per- 
missible. If  the  hyperacidity  is  the  cause  of  the  atony,  we  favor 
restriction  of  proteid  diet  and  a  preponderance  of  amylaceous  food, 
according  to  principles  laid  down  elsewhere  (pp.  iS8,  189).  We  are 
strict  concerning  the  use  of  alcohol,  and  where  a  trial  proves  that  it 
injures  digestion,  we  generally  forbid  claret,  rhine  wine,  and  even 
small  amounts  of  beer.  But  where  a  trial  with  light  wines  demon- 
strates their  beneficient  action,  about  two  ounces  of  wine  with  each 
meal  may  be  permitted.  Whenever  the  hydrochloric  acid  is  dimin- 
ished, the  lighter  meat  varieties, — chicken,  pigeon,  birds, — iish,and 
boiled  sweetbreads  or  calves'  brains,  should  be  allowed  only,  but  a 
larger  amount  of  carbohydrates  conceded.  The  special  diet  is 
stated  more  explicitly  in  the  chapter  on  Dietetics  (p.  228). 

Constipation  is  a  serious  cause  and  constant  accompaniment  of 
gastric  atony  ;  it  must  therefore  receive  the  most  undivided  atten- 
tion. Purgatives  should  be  used  only  as  a  last  resort,  and  the  main 
reliance  placed  on  diet.  A  pint  of  cold  water,  preferably  Bedford 
Magnesia  Spring  Water,  in  the  morning  on  an  empty  stomach,  black 
(rye)  or  graham  bread,  abundance  of  vegetables, — turnips,  carrots, 
asparagus,  tomatoes,  rhubarb   plant,  beans,  peas,  lentils, — noodles, 


594  MOTOR    INSUFFICIENCY. 

macaroni,  barley,  sweet  compotes,  plums,  figs,  apples,  currents,  cran- 
berries, cider,  buttermilk,  kefyr,  sour  milk,  honey.  When  sweeten- 
ing is  desired,  milk-sugar  should  be  preferred  to  cane-sugar.  The 
use  of  these  articles  very  rarely  fails  to  bring  about  regular  passages 
without  medicines  (see  p.  236).  Whenever  a  drug  is  positively  un- 
avoidable, we  prefer  cascara  sagrada.  In  pronounced  atony,  con- 
stipation can  not  be  treated  by  this  diet  only,  because  it  increases 
the  weight  of  ingesta. 

The  hydropathic  treatment  consists  in  cold  morning  sponge 
baths,  cold  wet  packs,  and  Priessnits  bandages  to  epigastrium.  We 
are  in  the  habit  of  ordering  a  daily  bath  in  severe  neurasthenic 
myasthenia  which  contains  three  per  cent,  chlorid  of  sodium  and 
two  per  cent,  sodium  bicarbonate.  Temperature  of  bath  98°  F. ; 
to  remain  in  twenty  minutes.  When  taken  in  the  evening  this 
bath  favors  sleep. 

Electric  Treatment. — Intragastric  application  with  the  Einhorn 
electrode  within  the  stomach;  the  faradic  current  is  applied  up  and 
down  over  the  spinal  column  and  over  the  abdominal  muscles.  The 
constant  current  is  applied  in  the  same  manner  in  the  strength  of 
20  milliamperes  and  for  about  ten  minutes.  Systematic  massage, 
both  general  and  local,  over  the  stomach  is  an  important  adjuvant. 
(See  chapter  on  Electrical  Treatment,  pp.  288—295.) 

Medicinal. — This  form  of  treatment  should  be  as  limited  as  pos- 
sible.   The  most  approved  tonic  for  the  motor  function  is  strychnin. 

R  ■      Strychnin  sulphatis, 0.021  gm.      gr.    ^ 

Elixir  gentianse  cum  ferri  chloridi, 180.0  c.c.  §vj.        M. 

SiG. — f  Jss,   t.  i.  d. 

Where  the  hydrochloric  acid  is  deficient  it  must  be  supplied  ; 
where  it  is  excessive  it  must  be  neutralized  by  the  following  : 

R .      Magnes.  ust. l5-0  ^ss 

Bismuth  carbonic, 

Natron  bicarbonat., aa  .    ,    .       ^.o  gj  -|-  gr.   xv 

Strychnin  sulphatis, o.  i  gr.  iss.  M. 

SiG. — One-half  teaspoonful  one  hour  after  meals. 

Creosote  and  orexin  are  claimed  by  competent  authorities  (Pick 
and  Penzoldt)  to  be  able  to  excite  the  peristalsis;  the  latter  maybe 
used  where  there  is  anacidity  or  subacidity. 

Lavage. — As  a  rule,  one  will  be  able  to  get  along  without  lavage 
in  the  first  stage  of  motor  insufficiency.     But  where  the  food  re- 


TREATMENT  OF  MOTOR  INSUFFICIENCY  OF  SECOND  DEGREE.      595 

mained  in  persistently  over  time,  we  have  seen  improvement  of 
muscular  tonicity  follow  the  rapidly  alternating  cold  and  warm  intra- 
gastric douche  (p.  286).  This  exerts  a  powerful  and  stimulating 
effect  also  on  the  secretion  when  it  is  defective  ;  when  the  latter  is 
excessive,  the  douching  should  be  carried  out  with  alkalin  water. 

Treatment  of  Motor  Insufficiency  of  the  Second  Degree. 
[Fully  Developed  Dilatation). — This  may  be  considered  under  three 
headings:     (i)   Dietetic,  {2)   Medical,  (3)  Surgical. 

The  diet  is  essentially  based  on  the  same  principles  as  in  simple 
myasthenia  ;  the  amount  of  liquid  permissible  must  not  exceed 
1500  c.c.  in  twenty-four  hours.  With  exaggerated  vomiting  and 
pains,  we  would  recommend  exclusive  feeding  by  the  rectum  for 
fourteen  days.  A  specified  diet  list  for  both  simple  atony  and 
pronounced  dilatation  will  be  found  on  pages  226  to  229.  It  is 
impossible  to  treat  the  latter  form  successfully  without  lavage; 
this  is  not  only  a  palliative  measure  of  great  value,  but  in  cases 
of  atonic  dilatation  due  to  muscular  weakness,  and  not  dependent 
upon  mechanical  obstruction,  it  may  even  be  able  to  effect  a  cure, 
when  combined  with  other  means  presently  to  be  described. 

The  first  washings  are  carried  out  with  pure  warm  water,  but 
the  last  ones  are  done  with  solutions  adapted  to  the  chemical  and 
septic  states  present  in  the  organ.  For  instance,  if  there  is  great 
excess  of  hydrochloric  acid  and  fermentation  by  sarcinae  and  yeast, 
sodium  biborate  or  bicarbonate  should  be  added,  as  these  salts  are 
not  only  antacid,  but,  with  regard  to  these  organisms,  antiseptic. 
If  there  is  butyric  or  lactic  acid  fermentation,  boracic  acid,  three 
per  cent.,  salicylic  acid,  0.3  per  cent.,  creolin  or  lysol,  10  to  15 
drops  to  a  quart,  should  be  used ;  but  the  stagnation  can  not  be 
prevented  from  recurring  by  these  means  unless  the  motility  is 
improved  by  other  treatment. 

Electricity  should  be  employed  externally  and  internally,  as 
described  in  a  previous  chapter  devoted  to  this  subject  (p.  288). 

Massage  undoubtedly  improves  the  gastric  musculature,  but 
should  only  be  used  on  days  when  the  stomach  has  been  washed 
out,  because  the  mechanical  compression  may  force  stagnating 
masses  into  the  intestines,  thus  spreading  the  putrefaction. 
Abdominal  bandages  properly  adapted  and  applied  have  proved  a 
valuable  palliative  measure.  Hydrotherapeutic  applications  are 
indispensable,  and  should  be  used  as  described  in  the  paragraph 
devoted  to  the  consideration  of  that  treatment  (p.  295). 


596  MOTOR    INSUFFICIENCY. 

Medicinal  treatment  has  a  twofold  object:  (i)  To  promote  the 
motor  function  ;  (2)  to  prevent,  so  far  as  possible,  gastric  fermenta- 
tion and  decomposition.  The  only  drug  in  which  we  have  any 
faith  for  improving  gastric  peristalsis  is  strychnin  sulphate ;  it 
should  be  given  in  heavy  doses,  not  less  than  ^V  °^  ^  grain  for 
adults,  t.  i.  d. 

Boas  combines  strychnin  with  an  antifermentative  in  the  follow- 
ing manner : 

R  .     Strychnin  sulphatis, 0.0022  gm.  gr.   J^ 

Codein  phosphoric, 0.03       "  gr.  1 

Bismuth  saHcylici  basic, 0.5         "  gr-  viiss.     M. 

SiG. — One  powder  taken  after  each  meal. 

F.  Kuhn  has  proposed  salicylic  acid,  0.5  gm.  a  dose,  salicy- 
late of  sodium,  15  to  30  grains,  saccharin  and  sodium  benzoate, 
of  each  from  10  to  30  grains  a  dose,  to  counteract  gastric  fer- 
mentation. Carbolic  acid  was  first  used  by  Naunyn  for  the  same 
purpose.  When  there  is  marked  lactic  or  butyric  acid  fermen- 
tation, there  is  not  a  better  agent  than  hydrochloric  acid  to 
counteract  it ;  20  to  30  drops  of  the  dilute  form  in  5ij  of  water, 
through  a  glass  tube.  Among  other  remedies  that  are  recom- 
mended are :  Salol,  naphthol,  betanaphthol  bismuth,  and  beta- 
naphthol  bismuth  benzoate,  or  benzonaphthol,  hydrochloric  and 
carbolic  acid.  Bouchard  is  very  enthusiastic  concerning  antifer- 
mentative treatment  of  gastrectasia,  but  it  is  certain  that  this 
treatment  alone,  without  lavage  and  proper  diet,  is  fallacious. 

Dujardin-Beaumetz  employs: 

R  .     Bismuth  salicyl. , 

Magnes.  usta., 

Sod.  bicarb., aa  10     150  gr.        M. 

SiG. — To  be  divided  into  30  powders  ;  one  powder  after  meals. 

Our  formula  for  gastric  fermentation,  particularly  when  asso- 
ciated with  putrid  diarrhea,  is  : 

R .     Betanaphthol.  bismuth,  benzoatis,       8      3  ij 

Bismuth  salicylatis, 8      ^ij 

Magnesise  ustse, 8      ^^ij 

Saccharin,       I      ^j 

Menthol, 8      ^ij.  M. 

SiG. — To  be  divided  either  into  12,  24,  or  36  powders  to  suit  the  indications;  if 
there  is  much  fermentation,  it  should  be  divided  into  12  powders,  and  one  given  three 
times  daily.  Otherwise  it  should  be  divided  into  24  powders,  and  one  given  every  three 
hours. 


SURGICAL    TREATMENT    FOR    DILATATION.  59/ 

Evvald's  formula  for  prevention  of  gastric  fermentation  is  the 
following : 

U.      Resorcin  resublim., 5.0 

Bismuth  salicyl., 

Pulv.  rad.  rhei, 

Natrii  sulphur, aa  10. o 

Sacch.  lact. , 15.0.  M. 

SiG. — Make  a  powder ;   a  knife-blade  full  twice  daily. 

When  HCl  secretion  is  lost,  dilute  HCl  should  be  administered, 
according  to  the  formula  given  on  page  450;  if  HCl  is  not  well 
tolerated,  pancreatin  should  be  tried  according  to  the  principles 
given  on  page  451. 

For  improving  the  appetite,  strychnin,  orexin,  HCl,  and  lavage, 
are  the  most  approved  means  of  therapy. 

For  vomiting,  lavage  is  the  most  efficacious  treatment,  but  if  it 
fails  resorcin,  gr.  ij  in  5ss  of  chloroform  water,  or  a  hypodermic 
injection  of  morphin  and  atrophinae  sulphatis  will  be  called  for. 
As  a  rule,  menthol  and  chloroform  do  not  disappoint  when  used 
for  the  relief  of  vomiting.     The  following  formula  is  practical  : 

Be.     Mentholi,      i.o  gr.  xvj 

Chloroform, 1. 5  gtt.  xxiv 

Elixir  simplic, q.s.  60.0  f5ij.  M. 

SiG. — f^ij  every  hour. 

Insomnia  must  sometimes  be  treated,  as  these  patients  impera- 
tively need  rest ;  for  this  purpose  chloral,  grs.  xv,  per  enema,  is 
most  advisable.  Correction  of  hyperacidity  will  often  induce  sleep. 
Sulphonal  and  chloral  combined,  of  each  eight  grains,  will  produce 
a  more  lasting  sleep  than  if  either  is  used  alone.  Trional  is  recom- 
mended for  the  same  purpose  by  Boas. 

Surgical  Trealvient. — The  operations  that  have  been  suggested 
for  the  relief  of  motor  insufficiency  vary  according  to  the  object 
to  be  accomplished.  Motor  insufficiency  from  simple  atonic  dila- 
tation may  be  relieved  by  reducing  the  size  of  the  stomach  by 
excision  of  a  piece  of  the  same, — an  operation  known  as  gastro- 
plication  or  gastrorrhaphy  (Weir). 

If  the  pylorus  is  stenosed  by  a  simple  cicatrix  or  hyperplastic 
sphincter,  Loreta's  digital  divulsion  of  the  pylorus  is  an  operation 
which,  judging  from  the  statistics,  is  an  unsafe  and  unreliable  pro- 
cedure. The  pyloroplastic  operation  of  von  Heinecke-Milkulicz, 
which  Boas  terms  the  ideal  surgery  for  the  relief  of  pyloric 
stenosis  of  a  benign  nature,  produces  more  permanent  results. 


598  MOTOR    INSUFFICIENCY. 

Gasti:o-enterostomy  and  resection  of  the  pylorus,  as  well  as 
gastrorrhaphy,  an  operation  originated  by  Dr.  Heinrich  Bircher,  a 
Swiss  surgeon,  will  come  under  consideration.  The  indications 
for  these  operations,  and  their  technic,  are  subjects  concerning 
which  the  reader  must  be  referred  to  the  chapter  on  Gastric  Sur- 
gery. The  larger  portion  of  dilatations  are  undoubtedly  due  to 
some  obstacle  to  the  exit  of  the  chyme  (ischochymia,  as  Einhorn 
calls  it),  and  it  is  rational  to  presume  that  purely  medical  means 
can  not  effect  a  permanent  cure  of  these  conditions.  But  the 
obstructions  or  obstacles  to  the  chyme  are  not  all  found  in  the 
stomach  itself,  for  in  the  account  given  under  the  etiology,  dis- 
tended gall-bladder,  gall-stones  impacted  in  the  diverticulum  of 
Vater,  floating  kidney,  duodenal  cicatrices  and  neoplasm,  peritoneal 
adhesions,  etc.,  have  been  referred  to,  and  all  of  these  give  their 
separate  and  distinct  indications  for  operation. 

DIET   FOR    MOTOR   INSUFFICIENCY    OF   THE   FIRST   DEGREE 
—ATONY— MYASTHENIA  {Boas). 

Calories. 

8  A.  M. — 100  gm.  of  milk,  50  gm.  of  toast,  30  gm.  of  butter 401.2 

10  A.  M. — 5ogm.  of  wheat  bread,  30  gm.  of  butter,  60  gm.  of  scraped  beef,  4  15.2 
12  M. — 150  gm.  of  boiled  beef,  50  gm.  of  potato  puree  or  macaroni,  .  .  439.3 
3P.M. — 100  gm.  of  milk,  50  gm.  of  Zwieback 401.2 

7  p.  M. — 100  gm.  of  cold  ham  or  beef,   150  gm.  of  wheat  bread,  30  gm. 

of  butter, 557.5 

Total,  22144 
About  three  ounces  of  good  port  wine  or  claret  may  be  allowed 
during  the  day. 

DIET    FOR    MOTOR    INSUFFICIENCY    OF    THE    SECOND    DEGREE 
—PYLORIC    STENOSIS-MYASTHENIC    DILATATION   [Hemmetcr). 

Calories. 

8  A.  M. — 100  gm.  of  Mosquera's  beef  chocolate,  or  50  gm.  of  tea  with  50 

gm.  of  milk,  sweetened  with  saccharin,   no  sugar,   50  gm.  of 

toast, 195-5 

10  A.M. — 100  gm.  of  scraped  lean  beef 437 -o 

30  gm.  of  toast, 77.7 

TO  gm.  of  butter, 71.3 

Total,   586.0 

12  M. — 150  gm.  of  roast  beef, 320.7 

50  gm.  of  potato  puree, 63.7 

Total,  384.4 
In  place  of  the  potato  puree,  the  same  of  spinach,  carrots,  peas, 
or  beans  may  be  allowed  in  the  same  quantity. 


LITERATURE    ON    DILATATION    OF    THE    STOMACH.  599 

Calories. 

2  p,  M. — 50  gm.  of  cream, io7-3 

4  P.  M. — 100  gm.  of  tea  or  coffee  with  milk,  no  sugar,  but  saccharin,  50 

gm.  of  toast, 195-5 

7  P.M. — 100  gm.  of  broiled  white  or  yellow  perch  or  oysters, 71-75 

50  gm.  of  wheat  bread, 129.0 

10  gm.  of  butter, 71.3 

100  gm.  of  cream, 214.0 

9  P.  M. — 50  gm.  of  cream 162.3 

Total,   1885  15 

In  atony  and  dilatation,  as  well  as  in  carcinoma,  experience  is  the 
best  guide  for  enlarging  and  varying  the  diet.  Every  new  article 
of  diet  must  at  first  be  tried  with  great  caution  ;  if  liquids  are  well 
tolerated,  they  may  be  increased,  and  soups  allowed  for  the  noon 
meal.  The  daily  lavage  should  at  times  be  undertaken  at  hours 
when  a  test-meal  can  be  secured  thereby,  which  will  incidentally 
instruct  the  physician  concerning  the  digestibility  of  new  foods  and, 
what  is  more  important,  the  state  of  the  motor  function. 

LITERATURE  ON  DILATATION  OF  THE  STOMACH. 

1.  Klemperer,  "  Ein  Fall  geheilter  Magenerweiterung,"  Deutsche  med.  Wo- 
chenschr.,  1889,  Nr.  9. 

2.  Kansche,  "Unters.  ijber  die  funkt.  Resultate  von  Operat.  am  Magen." 

3.  Rosenheim,  "  Ueber  d.  Verhaltn.  d.  Magenfunkt.  nach  Resekt.  des  car- 
cinomat.  Pylorus,"  Deutsche  med.  Wochenschr.,  1892,  Nr.  40. 

4.  Dunin,  "Resultate  der  Gastroenterostomie  bei  narb.  Pylorusstenose," 
Ceniralbl  f.  Chirurg.,  1893,  Nr.  36. 

5.  Rydygier,  "  Zur  Magendarmchirurgie,"  IVien.  klin.  Wochenschr.,  1894, 
Nr.  10. 

6.  Riegel,  "  Zur  Diagnose  u.  Behandlung  der  Magenerweiterung,"  Deutsche 
med.  Wochenschr.,  1886,  Nr.  37. 

7.  V.  Johann  Peter  Frank,  "  De   cur.  horn.  morb.  epit.,"  lib.  v,  pars  6, 
p.  666. 

8.  Boas,  "  Diagnostik  u.  Therapie  der  Magenkrankheiten,"  2.  Theil,  S.  1 1 1, 
Leipzig,  1893. 

9.  Boas,  Deutsche  med.  Wochenschr.,  1893,  Nr.  39,  und  Munchener  med. 
Wochenschr.,  1893,  N""-  43- 

JO.  Ewald,  Berl.  k/m.  Wochenschr.,  1890,  Nr.  12. 

11.  Hufschmidt,   Wiener  klin.  Wochenschr.,  1893,  Nr.  3. 

12.  Bartels,  Berl.  klin.  Wochenschr.,  1877,  Nr.  30. 

13.  Litten,  Verhandlungen  des  VI  Congr.  f.  innere  Med.,  1887. 

14.  Landau,  "  Die  Wanderniere  der  Frauen,"  Berlin,  1881. 

15.  V.  Ziemssen,  "  Ueber  physik.  Behandl.  chron.  Magendarmerkrankung," 
Leipzig,  1888. 


600  MOTOR    INSUFFICIENCY. 

i6.  Kussmaul,  "  Zur  peristalt.  Unruhe  des  Magens,"   Volkin.  klin.  Vortrdge, 
Nr.  i8i. 

17.  Beaumont,  "Experiin.  on  the  Gastr.  Juice,"  1838. 

18.  Penzoldt  {loc.  ctt.),  a.  a.  O.,  S.  27.     (See  reference  No.  52,  p.  600.) 

19.  V.  Basch,  Berl.  kliti.   Wochenschr.,  1889,  Nr.  19,  S.  433. 

20.  Dujardin-Beaumetz,  Berl.  klin.  Wochenschr.,  1890,  Nr.  31. 

21.  Hilton  Fagge,  Guy's  Hosp.  Rep.,  xviii,  Virchow's  Jahresb.,  1873,  B.  H., 
S.  155. 

22.  Erdmann,   Virchow's  Archiv,  Bd.  XLIII,  S.  295. 

23.  Traube-Kundrat,  "  Handbuch  d.  Kinderkrankh.,"  Bd.  iv. 

24.  Oser,  Artikel  "  Magenerweiterung  "  in  Eulenburg's  "  Realencyclopadie." 

25.  Riegel,   "  Ueber  Diagnostik  u.  Therapie  der  Magenkrankheiten,"    Volk- 
mann's  klin.  Vortr.,  Nr.  289. 

26.  V.  Frankl-Hochwart,  "Die  Tetanie,"  Berlin,  1891. 

27.  Bouveret  et  Devic,  Revue  de  Medec,  1892,  H.  i  und  11. 

28.  Jacobson  und  Ewald,  "  Ueber  Tetanie,"  Verhdlgn.  d.  Congr.  f.  innere 
Medizin,  1893,  S.  298. 

29.  Popofif,  Berl.  klin.  Wochenschr.,  1870,  Nr.  38  u.  40. 

30.  Rupstein,  Archiv  f.  Anat.  u.  Physiol.,  1874. 

31.  Hoppe-Seyler,  Deutsches  Archiv  f.  klin.  Med.,  Bd.  l,  S.  82. 

32.  Aufrecht,  Centralbl.f.  klin.  Med.,  1893,  Nr.  23. 

33.  Pacanowski,  "  Zur  physikal.  Diagnostik  d.  mechan.  Insuff.  d.  Magens." 

34.  Dehio,  Verhdlgn.  d.  Congr.  f.  innere  Med.,  1888. 

35.  Leube,  Archiv  f.  klin.  Med.,  Bd.  XVIII,  S.  207. 

36.  Ewald,  Therap.  Mo7iatshefte,  August,  1887. 

37.  Penzoldt-Faber,  Berl.  klin.  Wochenschr.,  1882,  Nr.  21. 

38.  V.  Einhorn,  "  Ueber  elektr.  Magen-  und  Darmdurchleuchtung,"  Therap. 
Monatshefte,  1892,  S.  128. 

39.  Reichmann   und   Heryng,    "Ueber  Gastrodiaphanie,"   Berl.  klin.    Wo- 
chenschr., 1892,  Nr.  51. 

40.  Kuttner  und  Jacobson,  Berl.  klin.  Wochenschr.,  1892,  Nr.  39  u.  40. 

41.  Chomel,  "  Des  Dyspepsies,"  Paris,  1857. 

42.  V.  Mehring,   "  Ueber  die  Funktion  des  Magens,"  Verhdlgn.  d.  Congr.  f. 
innere  Med.,  1893. 

43.  V.  Anrep,  Du  Bois'  Archiv,  1881. 

44.  Tappeiner,  Zeitschr.f.  Biol.,  Bd.  v,  471. 

45.  Petrequin,  Bulletin  de  Therap.,  x,  p.  239. 

46.  Wegele,  "Die  diatetische  Behandlung  der  Magendarmerkrankungen ; 
mit  einem  Anhang,  Die  diatetische  Kiiche." 

47.  A.  Rossler,  "  Ueber  die  Ausschaltung  der  Ernahrung  durch  den  Magen 
bei  Dilatatio  ventriculi,"  Wiener  klin.  Wochenschr.,  1893,  Nr.  40. 

48.  Anderson,  British  Med.  Jour.,  May  10,  1890. 

49.  Donkin,  The  Lancet,  September  27,  1890. 

50.  Huber,  Deutsches  Archiv  f.  klin.  Med.,  Bd.  XLVii. 

51.  Fleiner,     "Ueber    die     Behandl.     einiger    Reizerschein.    u.    Blut.    des 
Magens,"  Verhdlgn.  d.  Congr.  f.  innere  Med.,  1894,  S.  309. 

52.  Penzoldt,  "  Die  Magenerweiterung,"  Erlangen,    1875.     (History  of  the 
subject.) 


LITERATURE    ON    DILATATION    OF   THE   STOMACH.  6oi 

53.  Zabludowski,  "  Zur  Massagetherapie,"   Berl.   klm.    Wochenschr.,    1886, 
Nr.  26  ff.  u.  36. 

54.  Einhorn,  Berl.  klin.  Wochenschr.,  1891,  Nr.  23. 

55.  Winternitz,  Deutsche  Medicinalzeitutig,  1891,  Nr.  38. 

56.  Rosenthal,  "  Magenneurosen  und  Magenkatarrh,"   Wien,    1886,  S.  181. 

57.  Winternitz  und  Baum,   Wiener  med.  Presse,  1873,  Nr.  17. 

58.  A.  Bokai,  "  Wirkung  des   Ouassin   betr.,"     Pester  vied.-chirurg.   Presse, 
1893,  Nr.  45. 

59.  ^WXxazxvn,  Miinchefier  med.  Wochenschr.,  1893,  Nr.   29. 

60.  Kuhn,  Detitsche  med.  Wochenschr.,  1892,  Nr.  49  und  50. 

61.  Senator,  "  Ueber  einige  neuere  Arzneimittel,"   Berl.  klm.  Wochenschr., 
1885,  Nr.  I. 

62.  H.  Bircher,  Correspondettzbl.  f.  Schweizer  Aerzte,  1891,  Nr.  23. 

63.  Nauvverk,  D.,  Archiv  f.  klin.  Med.,  Heft.  5  u.  6.,  vol.  xxi,  p.  573,  1878. 

64.  Marten,  Lancet,  April  2,  1890,  p.  230. 

65.  Landerer,  Inaug.-Dissert.      Freiburg,  1879. 

66.  Deiters,  Inaug.-Dissert.      Greifsvvalde,  1889. 

67.  S.  Cecchini,  Rassegna  di  Scienza  mediche,  1886. 

68.  Grundzach,    Wien.  med.  Presse,  Nr.  28,  1891. 

69.  Mueller-Warnek,  Berl.  klin.  Woche7ischr.,  No.  30,  429,  1877. 

70.  Bruhl,  Gaz.  des  Hopitatix,  1891. 

71.  Pertick,  Archiv  f.  path.  Anat.  u.  Phys.,  cxiv,  1888,  Heft  3,    S.  98. 

72.  Thiebaut,  These  de  Nancy,  1884. 

73.  Hunter,  New  York  Med.  Record,  p.  273,  1889. 

74.  Lepoil,  These  de  Paris,  1878. 

75.  Montaya,  These  de  Paris,  1881. 

16.  Debove,  Sac.  Med.  des  Hopit.,  12  Dec,  1886. 
']■].  Kuhn,  Zeitschr.f.  klin.  Med.,  1892,  Heft.  5  und  6. 

78.  G.  See  et  A.  Mathieu,  Rev.  de.  Med.,    10  Mai  et  18  Sept.,  1884. 

79.  Plempius,  et  suivants,  cites  par  D.-Beaumetz,   "  Traitement  des  mal.  de 
rEstomac,"  Paris,  1893. 

80.  Revilliod,  Revue  de  Med.,  de  la  S.  Romande,  No.  i,  1885. 

81.  Heynsius,  Weekblad  van  het  A^ederlandsch.     Tydschrift  voor  Genesk, 
Nr.  37,  1874. 

82.  Leichtenstern,  Ziemssen's  Handbuch,  2.  Aufl.,  Bd.  vii,  2,  pp.  411-418. 

83.  Moncorvo,  Rio  de  Janeiro,  broch.,  1883. 

84.  Comby,  Arch.  Gen.  de  Med.,  Aout,  1884. 

85.  Mattheides,  Inaug.-Dissert.,  Erlangen,  1890. 

86.  Schmidt,  Berl.  klin.  Wochenschr.,  1886,  Nr.  33. 

87.  Pepper,  Philada.  Med.  Times,  May  i,  1871. 

88.  Francon,  Lyon  Med.,  7  Aout,  1887. 

89.  Malibran,  These  de  Paris,  1885. 

90.  Jaworski,  Wien.  med.  Wochenschr.,  No.  16,  1888. 

91.  Leo,  "  Diagn.  der  Krankh.  d.  Verdauungsorgane,"  p.  41.    Berlin,  1892. 

92.  Duchon-Doris,  These  de  Paris,  1887. 

93.  Wagner,   Berl.   klin.    Wochenschr.,  Nr.  16,  p.  229,   und   Nr.  25,  p.  361, 
18.  April  und  20.  Juni,  1881. 

94.  Meyer,   Virc how's  Archiv,  Bd.  cxv,  p.  326,  1889. 

95.  Newmann,  Lancet,  5  Dec,  1868. 


602  MOTOR    INSUFFICIENCY. 

96.  Buist,  S.  Somers,  Ainer.  Jour,  of  Med.  Science,  Oct.,  1870. 

97.  Chiari,  Wlen.  vied.  Blait,  Nr.  3,  1881. 

98.  Hofmann,  Anzeiger  d.  Ges.  d.  Aerzte  in  IVien,  Nr.  12,  1881. 

99.  Lefevre,  Arch.  Geti.  de  Med.,  tome  xiv  et  xv,  1842. 
100.  Remond  (de  Metz).  Gaz.  des  Hopit.,  14  Nov.,  1891. 
loi.  Neumann,  Deutsche  Klinik,  Nr.  2  und  3,  1861. 

102.  Galliard,  Assoc.  Fran9aise,  Congres  de  Rouen,  1883. 

103.  Laprevotte,  These  de  Paris,  1884. 

104.  D.-Beaumetz  et  D.  Ettinger,  Union  Medicale,  29  Janvier,  1884. 

105.  Gerhardt,  Berl.  klin.  IVochenschr.,  p.  74,  Januar,  1888. 

106.  F.  Miiller,  Ckarite  Annalen,  p.  283,  1888. ^ 

107.  Beurmann,  Gaz.  Hebd.,  No.  14,  1889. 

108.  Bugge,  Tidshrifl  f.  pract.  Med.,  Nr.  10,  1881. 

109.  Rosenbach,  Berl.  klin.   Wochenschr.,  Nr.  51,  p.  742,  1876. 

no.  Sigmund  Purjesz,  Deutsches  Arch.f.  klin.  Med.,  Bd.  xxiii,  p.  554,  1879. 

111.  Stoker,  "Hour-glass  Contract.  Stomach,"  Med.  Press  and  Circ, 
March  3,  1869. 

112.  Jago,  Med.  Times  and  Gaz.,  Oct.  12.,   1872. 

113.  Luigi  Mazotti,  Rivista  Clinica  di  Bologna,  Aout  et  Sept.,  1824. 

114.  Bauermeister,  Inaug.-Dissert.    Halle,  1890. 

115.  Saundby,  Deutsche  med.  Wochenschr.,  Nr.  42,  1896. 

116.  Kern,  Inaug.-Dissert.   Berlin,  1891. 
wj.  Thorowgood,  Lancet,  17  Fev.,  1872. 

118.  Baum,  Wien.  med.  Presse,  Nr.  17,  1873. 

119.  Beau,  Gaz.  Med.  de  Paris,  No.  5,  i860. 

120.  Hirschberg,  These  de  Paris,  1889. 

121.  Bardet,  Bull.  Gen.  de  Thcrap.,  1884,  p.  329. 

122.  Schliep,  Deutsches  Archiv  f.  klin.  Med.,  Bd.  xiii,  p.  445. 

123.  Traube,  "  Gesammelte  Abhandlungen,"  1871. 

124.  Talma,  "  Indicat.  z.  Magenoperationen,"  Berl.  klijt.  Wochenschr.,  1895. 

125.  Tilger,  "Traction  Diverticulum  of  Pyloric  Region,  Caused  by  Disloca- 
tion of  the  Gall-bladder,"  Virchow's  Archiv,  Bd.  cxxxiii.  Heft  2  ;  the  same 
author,  "  On  Congenital  Stenosis  of  the  Pylorus,"  loc.  cit. 

126.  Senator,  "On  Auto-intoxications,  etc.,"  Zeitschr.  f.  klin.  Med.,  Bd. 
VII,  84. 

127.  Schmidt-Monnard,  "  Hour-glass  Stomach,"  Mi'inch.  7ned.  Wochenschr., 

93- 

128.  Schreiber,  Archiv  f.  Verdauungskrankh.,  Bd.  11,  S.  423. 

129.  Poensgen,  "  Motor- Verricht.  d.  menschl.  Magens,"  Strassburg,  1882. 

130.  Quincke,  "  Dilatation  with  Rupture  into  Colon,"  Correspondenzbl.  f. 
Schweizer  Aerzte,  1 874. 

131.  Oppolzer,  "  Magenerweiterung,"   Wien.  med.  Wochenschr.,  1867. 

132.  Naunyn,  "Gastric  Fermentation  and  Motor  Insufficiency,"  Deutsch. 
Arch.f.  kiitt.  Med.,  Bd.  xxxi,  82. 

133.  Moritz,  "Gastric  Motility  with  Regard  to  Liquids  and  Semi-liquids," 
Verhandl.  d.  Naturforsch.  Versamml.,  Wien,  1894. 

134.  McNaught,  "  Dilatation  and  Eructation  of  Inflammable  Gas,"  Brit. 
Med.  Jour.,  1890. 

135.  R.  Maier,  "Congenital  Pyloric  Stenosis,"   Virchow's  Arch.,  Bd.  Cil. 


CHAPTER  VIII. 

ENTEROPTOSIS— GASTROPTOSIS. 

There  is  a  very  extensive  piece  of  work  concerning  the  diseases 
of  the  abdomen  in  the  fifth  volume  of  Virchoiu's  Archiv,  in  which 
this  subject  of  dislocations  is  treated  at  great  length  in  connection 
with  two  other  questions,  which,  we  believe,  have  not  been  suffi- 
ciently emphasized;  namely,  first,  in  connection  with  partial 
chronic  peritonitis,  and,  secondly,  in  connection  with  the  acute  dis- 
eases of  the  mucous  membranes,  especially  with  diphtheric  forms. 

Partial  peritonitis  of  the  female  sexual  organs,  and  especially 
their  appendages,  comes  under  consideration  in  connection  with 
dislocation  of  the  transverse  colon  and  stomach.  In  almost  all 
adults  partial  states  of  dislocation  of  the  viscera,  and  especially 
of  the  intestines,  occur  so  frequently  that  more  people  have 
this  displacement  than  a  normal  location  of  the  intestines  (Vir- 
chow,  loc.  cit}j.  The  French  authors  are  justified  in  assum- 
ing the  great  frequency  of  these  dislocations.  Undoubtedly,  the 
majority  of  all  civilized  peoples  have  a  certain  deviation  in  the 
location  of  their  intestines,  or,  in  other  words,  some  slight  degree 
of  enteroptosis.  While  it  is  undoubtedly  true  that  the  majority  of 
these  dislocations  are  due  to  sinking, — that  is,  ptosis,  or  a  descensus 
of  the  intestines, — nevertheless  the  contrary  is  also  found.  There  are 
also  dislocations  which  move  upward,  in  which,  for  instance,  the 
splenic  flexure  (flexura  linealis)  comes  to  a  position  above  the 
spleen  immediately  next  to  the  diaphragm,  and  others  in  which  the 
hepatic  flexure  moves  upward  far  under  the  liver.  This  upward  dis- 
tortion of  the  intestines  should  also  receive  careful  consideration. 
It  is  evident,  however,  that  every  decided  change  in  situation  of  this 
sort — especially  if  it  is  at  the  same  time  accompanied  by  kinking, 
or  if  considerable  deviation  in  the  direction  of  the  intestines  occurs 
(or,  as  it  has  been  expressed  by  Virchow,  when  "  anomalous  flex- 
ures "  arise) — must  bring  about  an  interference  with  the  passage  of 
the  contents  of  the  intestines;  and  therefore  nothing  is  more  fre- 

603 


604  ENTEROPTOSIS — GASTROPTOSIS. 

quent  than  to  find,  at  the  necropsy,  collections  of  fecal  matter  just 
at  these  angles  and  flexures,  or  that  accumulations  of  gases  occur 
while  adjacent  parts  of  the  intestines  are  contracted.  Thus  we  get 
a  picture  in  which  much  contracted,  one  may  even  say  spastically 
contracted  parts  of  the  intestines  alternate  with  much  dilated  por- 
tions. It  must  be  emphasized  that  the  colon  is  the  main  seat  of 
difficulty,  and  the  dislocation  which  occurs  most  frequently  is  a 
lowering  of  the  transverse  colon,  which  often  sinks  under  the  navel 
and  sometimes  even  to  the  true  pelvis,  and  then  forms  a  V-shaped 
loop,  or  one  with  two  parallel  legs.  The  next  most  frequent  point 
is  the  iliac  flexure,  which  may  show  all  the  possible  varieties  of 
descents  and  displacements  toward  the  right.  The  two  large 
flexures  in  the  upper  part  of  the  abdomen — the  hepatic  and  the 
splenic — are  third  in  the  order  of  frequency  of  dislocations.  The 
cecum  may  also  be  drawn  into  similar  displacements,  and  may 
sometimes  move  under  the  liver,  and  at  other  times  sink  down  to 
the  true  pelvis.  These  states  are  relatively  frequent,  although  little 
attention  has  been  given  to  these  very  chronic  conditions,  because 
it  is  not  known  to  what  extent  certain  symptoms  in  life  are  con- 
nected with  them,  and,  as  a  rule,  no  one  dies  from  these  displace- 
ments. 

In  the  treatise  by  Virchow,  before  mentioned,  it  was  distinctly 
proven  that  anomalous  adhesions  frequently  occur  simultaneously 
with  these  states ;  for  instance,  growing  together  of  the  intestines 
with  each  other — that  is,  the  various  curves  and  loops  among  them- 
selves, and  at  other  times  with  the  adjacent  organs.  The  hepatic 
flexure  of  the  colon  to  a  great  extent  becomes  connected  with  the 
gall-bladder  and  the  whole  apparatus  of  the  evacuating  gall  pas- 
sages ;  and,  on  the  other  hand,  the  splenic  flexure  comes  into  close 
connection  with  the  spleen  and  the  diaphragm,  and  the  iliac  flexure 
with  the  sexual  organs,  especially  in  women.  There  are  a  number 
of  reciprocal  relations  which  establish  beyond  a  doubt  that  tractions 
must  result  from  them,  such  as  pulling  of  the  various  parts  among 
one  another,  which  under  certain  circumstances  may  develop  injuri- 
ous effects. 

The  relation  of  partial  peritonitis  to  visceral  dislocations  is  more 
difficult  to  understand,  and  in  this  respect  two  relations  are  to  be 
distinguished  ;  namely,  a  primary  one,  in  which  peritonitis  occurs 
earlier,  and  a  secondary  one,  in  which,  conversely,  the  peritonitis  is 


ENTEROPTOSES    DUE    TO    SECONDARY    PERITONITIS.  605 

caused  by  the  dislocation  and  by  the  other  processes  going  on 
within  the  adherent  part  of  the  intestines. 

Concerning  the  first,  we  have  a  clear  example  in  the  recognized 
cases  of  circumscribed  peritonitis,  which  are  caused  by  processes 
starting  from  the  gall-bladder  (perihepatitis,  peritonitis  cystica), 
where  adhesions  are  formed  within  the  environment  of  the  gall  pas- 
•  sages;  this  is  followed  by  a  shifting  of  the  parts  among  each  other, 
since  the  adhesive  masses  gradually  contract  and  the  retraction 
proceeds  further  and  further.  On  the  other  hand,  secondary  peri- 
tonitis is  much  more  difficult  to  prove  in  cases  where  one  is  con- 
fronted with  the  completed  process ;  one  can  only  recognize  it 
where  fresh  processes  still  exist.  These  recent  processes  exist 
mostly  in  those  cases  where  a  severe  disease  of  the  mucous  mem- 
branes, extending  to  the  peritoneum,  causes  a  bending  or  kinking 
of  the  intestine. 

Virchow  was  the  first  to  draw  attention  to  these  facts  in  studies 
on  dislocations  with  so-called  diphtheritic  dysentery,  which  was, 
formerly,  as  a  rule,  considered  a  disease  of  the  rectum  (proctitis) 
until  it  was  ascertained  that  dysentery,  similarly  to  other  forms 
of  intestinal  inflammation,  may  appear  distributed  in  a  variable 
manner,  so  that  the  foci  of  inflammation  are  separated  by  long 
stretches  of  normal  mucous  membrane.  Entirely  normal  sections 
are  succeeded  by  new  areas  of  very  severe  disease,  so  that  one  may 
distinguish  a  sort  of  interrupted  localization.  The  questions  were 
raised,  How  did  this  interruption  arise  ?  how  did  it  come  about  that 
new  areas  of  disease  are  formed  at  intervals  ?  Virchow  suggested 
that  the  anomalous  flexure,  just  as  the  normal,  is  in  itself  a  motive 
for  localization,  in  that  it  brings  with  it  a  retardation  in  the  pas- 
sage of  the  contents  of  the  intestines,  which  contain  injurious  sub- 
stances that  react  upon  the  mucous  membrane,  and  from  which  the 
irritative  process  is  developed.  It  is  exactly  the  same  thing  which 
we  see  in  stenoses,  where  further  disturbances  arise  above  the 
obstruction,  or  with  incarcerated  hernise,  where  the  inflammation 
develops  in  the  intestinal  part  above  the  incarceration,  and  sooner 
or  later  extends  to  the  peritoneum. 

These  consequences  of  partial  enteroptoses  due  to  acute  inflam- 
mations are  easily  recognized.  In  this  way  severe  secondary 
peritonitis  may  arise  {Archiv  fur  patJiologiscJie  Anatoviie  21.  Physi- 
ologie,  1 87 1,  LI  I,  34). 

From   these   views   we    may   infer    that    enteroptosis   is  not  an 
40 


6o6  ENTEROPTOSIS — GASTROPTOSIS. 

anatomical  process  which  is  connected  with  constant  clinical 
symptoms.  On  the  contrary,  the  symptoms  will  probably  be 
very  manifold,  according  to  the  special  pathological  circum- 
stances which  occur  in  various  cases.  Accordingly,  the  dis- 
ease in  each  case  will,  to  some  degree,  come  under  different  cate- 
gories, and  one  may  not  bring  diphtheria  or  colitis,  developed  in 
anomalous  flexures,  into  the  same  category  as  dislocation  pure 
and  simple ;  these  are  two  very  different  things  (Virchow).  We 
shall,  therefore,  have  to  decide  not  to  call  the  enteroptosis  an  en- 
tity, but  to  divide  it  into  several  groups  of  diseases  when  it  is  to 
be  regarded  symptomatologically  and  therapeutically.  We  are 
dealing  here  with  a  very  common  and,  if  we  could  count  the  cases, 
an  almost  normal  series  of  deviations,  which  only  from  time  to  time 
become  the  origin  of  severer  symptoms. 

Leshaft  has  shown  that  the  size  and  fullness  of  the  abdominal 
organs,  as  well  as  the  condition  of  the  abdominal  integument,  are 
important  for  the  reciprocal  conduct  and  relation  of  the  intra- 
abdominal organs. 

Every  abnormal  fullness  or  increase  in  size  of  one  of  these 
organs,  as  well  as  a  decrease  in  the  power  of  resistance  within  the 
compass  of  the  abdominal  integuments,  will  produce  a  change  in 
location, — a  sort  of  ptosis,  in  the  sense  of  Glenard.  It  has  been 
proved  that  a  descent  of  the  transverse  colon,  especially  the  right 
flexure,  carries  with  it  a  lowering  of  the  stomach  and  a  descent 
of  the  right  kidney.  It  is  evident  that  the  transverse  colon  does 
not  descend  spontaneously  (idiopathically)  without  pathological 
causes,  so  that  there  can  not  well  be  a  primary  enteroptosis ; 
it  is  caused  by  etiological  factors,  such  as  abnormal  adhesions, 
change  of  contents  (coprostasis),  anomalous  flexures  (Virchow), 
tumors,  etc.,  by  which  the  transverse  colon  is  pulled  down,  and 
with  it,  secondarily,  the  stomach  and  small  intestine,  and  eventu- 
ally the  kidney,  especially  on  the  right  side.  Therefore  most 
enteroptoses,  if  not  all,  are  of  secondary  nature. 

Dislocation  of  the  Kidneys. — Litten,  in  1887,  published  a 
monograph  concerning  the  relation  of  diseases  of  the  stomach 
to  changes  in  location  of  the  right  kidney,  in  which  he  empha- 
sized the  facts :  "  Concerning  the  anomalies  of  location  of  the 
kidney,  one  must  sharply  distinguish  dislocation  and  movability." 
Although  both  irregularities  often  occur  together  and  simul- 
taneously,   there    is    no    organic    necessity  for   the  same ;    rather. 


DISLOCATED    AND    MOVABLE    KIDNEY.  607 

both  processes  may  appear  entirely  independent  of  each  other, 
although  in  many  cases  one  finds  a  dislocated  and  a  movable 
kidney  in  the  same  individual.  Litten  distinguishes  the  fol- 
lowing relations  concerning  the  location  and  movability  of  the 
kidney:  First,  a  simple  dislocation  of  the  same;  this  is  more 
frequently  congenital  than  acquired.  The  congenitally  dislocated 
kidney  is  found  more  frequently  on  the  left  than  on  the  right,  and 
with  approximateh'  equal  frequency  in  men  and  women.  Often 
both  organs  are  dislocated.  Not  taking  into  account  the  most 
frequent  form  of  dislocation,  the  so-called  horseshoe  kidney,  in  which 
both  organs  are  united  into  one,  the  dislocated  kidney  is  found  either 
close  under  the  bifurcation  of  the  aorta,  or  above  the  promontor}- 
of  the  sacrum,  or,  finally,  above  the  sacro-iliac  synchondrosis.  With 
the  change  -in  location  there  is  almost  always  connected  an 
anomaly  of  the  origin  or  course  of  the  renal  arter}-,  while  the 
suprarenal  capsule  more  frequently  remains  in  its  place  and  does 
not  follow  the  kidney  to  which  it  belongs.  Congenital!}-  dis- 
located kidneys  are  almost  always  fixed  in  the  place  of  their  dis- 
location.    An  exception  to  this  is  the  movable  horseshoe  kidney. 

Acquired  dislocations  of  the  kidneys  are  chiefly  due  to  patho- 
logical enlargements  of  neighboring  organs  (spleen,  liver,  pan- 
creas, suprarenal  capsule),  and  are  found  higher  or  lower  than  the 
norm.al  and  nearer  to  or  further  from  the  vertebral  column.  The 
pressure  of  articles  of  clothing  (such  as  corsets,  belts,  girdles,  etc.) 
seems  to  have  considerable  influence,  by  which  the  liver,  and  with 
it  the  kidney,  is  pushed  down.  Consequenth'  this  anomaly  of 
location  is  found  less  frequently  left  than  right — more  frequently 
in  women  than  in  men.  By  the  sinking  of  the  liver — ^.^.,  in  con- 
sequence of  hydatid  cysts — the  kidneys  may  be  completely  turned 
around,  as  a  result  of  which  one  may  feel  the  inner  edge  with  the 
hilus  upward,  the  convex  edge  downward,  or  pointing  in  some 
other  abnormal  direction.  ]\Iost  frequently  in  this  form  of  disloca- 
tion one  finds  the  kidney  pushed  downward  and  inward ;  /.  e., 
toward  the  median  line.  This  form  of  dislocation  of  the  kidney, 
acquired  late  in  life,  may  become  movable;  it  is  almost  always 
replaceable  if  it  has  not  become  fixed  in  its  new"  location  by 
secondary  inflammation.  While  one  might  describe  the  above- 
mentioned  forms  as  dislocation  of  the  kidney  with  and  without 
movability,  we  now  come  to  the  forms  in  which  the  movability 
pla}'s    the    main    role,   dislocation  the    secondary    kind — movable 


6o8  ENTEROPTOSIS — GASTROPTOSIS. 

kidneys  with  and  without  dislocation.  Here  we  have  to  dis- 
tinguish two  main  classes:  (i)  the  wandering  or  floating  kidney; 
(2)  the  movable  kidney. 

The  floating  kidney  is  distinguished  by  the  mesonephron,  a 
mesenteric  fold  fastened  to  the  kidney,  which  generally  consists  ot 
two  plates,  between  which  the  organ  is  held  and  with  which  it  is 
surrounded.  The  presence  of  this  anomaly  is  always  to  be 
traced  back  to  a  congenital  disposition  of  the  peritoneum,  with 
consequent  stretching  of  the  renal  vessels.  Generally  one  finds 
at  the  autopsy  in  these  cases  that  all  the  folds,  protrusions  of  the 
peritoneum  and  mesenteries,  are  abnormally  long  and  lax,  and  the 
foramen  of  Winslow  is  very  wide,  corresponding  to  the  laxity  of 
the  lesser  omentum  and  the  ligamentum  hepatico-duodenale. 

If  one  uses  this  anatomical  arrangement  for  the  classification, 
and  does  not  designate  at  will  every  excessively  movable  kidney 
as  a  "  floating  or  wandering  kidney,"  as  is  frequently  done  from  a 
clinical  point  of  view,  it  is  evident  that  every  floating  kidney,  in 
the  sense  adopted  by  Litten,  must  be  congenital.  It  will  hardly  be 
possible,  therefore,  during  life  to  distinguish  these  two  processes 
from  each  other;  on  the  other  hand,  there  will  also  be  cases  in 
which  a  very  short  and  tight  mesonephron  will  restrict  the  extent 
of  wandering  of  the  floating  kidney.  A  sinmltaneous  permanent 
dislocation  of  the  kidney  may  be  present,  but  not  necessarily  ;  it 
happens,  occasionally,  that  a  floating  kidney  in  the  course  of  time 
becomes  fixed  and  permanent  in  any  abnormal  location  by  means  of 
perinephritic  processes,  so  that  in  spite  of  its  mesentery  it  is  no 
longer  movable.  Litten  has  reported  a  considerable  dislocation  in 
a  wandering  horseshoe  kidney,  where  one  portion  of  the  organ  lay 
in  the  right  inguinal  region,  while  the  opposite  part  lay  upon  the 
horizontal  ramus  of  the  right  os  pubis.  The  organ  could  be 
pushed  about  within  the  widest  limits,  and  it  also  moved  spontane- 
ously, causing  unpleasant  sensations  to  the  patient.  In  this  intra- 
peritoneal position  of  the  kidney  the  organ  seems  to  lie  immedi- 
ately under  the  abdominal  integuments,  where  one  can  not  only 
palpate  it,  but  can  sometimes  also  recognize  its  contour  distinctly 
through  the  abdominal  integuments.  Percussion  over  the  organ 
produces  in  these  cases  a  distinct  dullness,  not  a  tympanitic  sound, 
as  is  the  case  with  the  kidney  situated  extraperitoneally. 

The  movable  kidney  is  distinguished  from  the  normal  solely 
by    an    excessive    movability,  which   is  revealed   to   a    greater    or 


CAUSES    OF    DISLOCATED    AND    MOVABLE    KIDNEY.  609 

less  degree  (not  taking  into  account  respiratory  movability)  in 
changes  in  the  position  of  the  body.  Often  this  anomaly  is 
accidentally  recognized  in  manipulations  instituted  for  the  ex- 
amination of  the  abdomen.  A  dislocation  of  the  kidney  can  and 
often  does  exist  simultaneously  with  the  above-mentioned  con- 
dition, but  it  does  not  necessarily  have  to  exist.  We  find  the 
right  kidney  more  frequently  movable  than  the  left  (the  propor- 
tion being  15  to  i),  and  the  anomaly  is  more  frequent  in  women 
than  in  men  (the  proportion  being  85  to  16).  The  degree  of 
movability  seems  to  be  chiefly  dependent  upon  the  varying  laxity 
of  the  part  of  the  peritoneum  descending  in  front  of  the  kidney, 
as  well  as  upon  the  abundance  or  absence  of  the  perinephritic  or 
subperitoneal  adipose  tissue  in  the  region  of  the  loins,  and  the 
greater  or  lesser  power  of  resistance  of  the  intra-abdominal  organs, 
including  the  abdominal  integuments. 

One  can  often  feel  the  kidney  so  distinctly  that  it  may  be 
palpated  with  anatomical  exactness,  although  it  lies  extra-peri- 
toneally,  separated  from  the  anterior  abdominal  wall  by  intestinal 
loops;  consequently  it  gives  forth  a  decided  tympanitic  sound, 
although  one  can  press  it  very  close  to  the  abdominal  wall.  The 
degree  of  dislocation  is  just  as  variable  as  the  degree  of  movability  ; 
in  most  cases  we  find  only  slight  dislocations  from  the  normal  posi- 
tion, downward  and  inward.  In  by  far  the  greater  number  of  cases 
this  condition  is  acquired,  especially  in  the  years  between  twenty 
and  forty. 

Etiologically,  the  following  factors  seem  to  have  the  greatest 
influence:  The  disappearance  of  the  fat  in  the  adipose  capsule  in 
which  the  kidney  is  held — through  this  the  kidney  becomes  mov- 
able in  this  capsule  ;  the  disappearance  of  the  perinephritic  adipose 
tissue,  through  which  the  kidney,  and  also  its  fat  capsule,  are  moved 
out  of  place;  further,  the  laxity  of  the  peritoneum,  the  increase  in 
the  weight  of  the  liver,  together  with  the  respiratory  displacement 
of  the  same,  prolapsus  of  the  uterus  and  of  the  vagina,  carcinoma 
and  retroflexions  of  the  uterus,  herniae,  weakness  and  laxity  of  the 
abdominal  walls,  and,  above  all,  the  much-discussed  enteroptosis. 
Also  heavy  lifting,  coughing,  pressing,  repeated  pregnancies,  vom- 
iting, as  well  as  traumatism  and  violent  agitation,  are  given  as 
causes.  The  most  frequent  cause  for  the  movability  of  the  right 
kidney  seems,  however,  to  be  lacing  with  corsets,  belts,  and  girdles. 
Kleiner  {loc.  cit)  gives  several  illustrations  of  this  effect.     Thus,  von 


6lO  ENTEROPTOSIS GASTROPTOSIS. 

Fischer-Benzon,  in  his  dissertation  from  the  pathological  institute 
at  Kiel,  states  that  in  21  cases  of  movable  kidney  there  was  found 
in  1 1  cases  a  furrow  in  the  liver  due  to  lacing. 

By  lacing  a  decided  pressure  is  exerted  upon  the  lower  part  of 
the  thorax,  by  which  this  is  greatly  narrowed  and  the  organs  lying 
within  it  compressed.  The  liver,  being  the  largest  and  least  com- 
pressible of  these  organs,  will  suffer  especially.  The  liver,  and  the 
kidney  closely  connected  with  it,  are  pushed  down,  and  the  latter 
must  participate  in  the  respiratory  excursions  of  the  liver. 

H.  Schmid  (Penzoldt  and  Stintzing's  "  Handbuch  d.  Therapie," 
Bd.  VI,  S.  345)  regards  the  renal  vessels  as  the  most  important 
attachments  of  the  kidney — if  the  vessels  are  abnormally  long,  an 
essential  support  is  lost.  L.  Knapp  {loc.  cit)  looks  upon  uterine 
displacements  and  consequent  dragging  upon  the  ureters  as  a 
frequent  cause. 

Since  the  respiratory  movements  of  the  diaphragm  are  com- 
municated to  the  kidney,  the  respiratory  movability  of  the  kidney 
may  be  regarded  as  physiological.  The  question  is  :  Can  we  prove 
this  respiratory  movability  of  the  kidney,  and  under  what  circum- 
stances? This  depends  especially  upon  the  various  individual 
conditions  in  the  person  to  be  examined. 

Method  of  Palpating  the  Kidneys. — The  chances  of  feeling  the 
respiratory  movability  of  the  right  kidney  will  vary  according  to 
the  relaxation  and  the  degree  of  resistance  of  the  abdominal 
integuments,  the  control  and  experience  of  the  patient  in  breath- 
ing, and  according  to  the  manual  dexterity  of  the  examiner.  It 
is  especially  important  that  the  individual  in  question  inspire 
deepl}^;  this  can  be  learned  easily  enough  by  practice.  The 
examiner  himself  must  not  cause  any  pain  or  tension  of  the  ab- 
dominal integuments  by  his  manipulations.  It  will  then  be  pos- 
sible in  many  cases,  by  means  of  the  bimanual  method  of 
examination,  to  feel  the  kidneys,  especially  the  right  one,  as  it 
is  more  easily  palpable.  It  would,  however,  be  entirely  false  to 
believe  that  one  could  only  prove  the  respiratory  movability  ot 
the  kidneys  in  females,  and  especially  in  multipara.  On  the  con- 
trary, it  may  be  shown  with  the  greatest  distinctness  in  men  and 
girls,  and  even  in  small  children.  In  bimanual  examination, 
in  order  to  feel  the  right  kidney  the  left  hand  is  placed  immedi- 
ately in  the  rear,  under  the  edge  of  the  ribs  on  the  right  side, 
while  the  tips  of  the  fingers  of  the  right  hand  similarly  placed 


BIMANUAL    PALPATION    OF    THE    KIDNEY.  6ll 

together  take  the  corresponding  position  at  the  lower  arch  of 
the  ribs  on  the  same  side ;  on  gradual  downward  pressure  one 
feels  a  larger  or  smaller  part  of  the  organ  between  the  fingers 
during  deep  inspiration.  The  deeper  the  inspiration,  the  greater 
the  portion  of  the  kidney  which  appears,  until  with  forced  in- 
halation one  may  sometimes  feel  the  whole  organ  pressed  out 
under  the  arch  of  the  ribs,  and  can,  with  the  greatest  distinctness, 
examine  it  by  palpation  between  both  hands.  If  the  fingers 
of  both  hands  are  pressed  together,  the  kidney  escapes  from  the 
hands,  and  the  person  examined  feels  a  slightly  unpleasant  sen- 
sation, and  sometimes  a  decided  sensation  of  pressure  or  pain,  or 
a  distinct  jerk.  Naturally,  the  abdominal  walls  must  not  be  too 
adipose,  otherwise  palpation  is  impossible.  The  knees  and  thighs 
of  the  patient  must  be  flexed.  This  escaping  of  the  kidney  from 
the  hands  upon  pressure  is  very  characteristic. 

With  this  method  of  examination  one  may  get  a  precise 
conception  of  the  size,  consistency,  and  thickness  of  the  organ ; 
possibly  neoplastic  formations,  lobulations,  irregularities,  even 
granulations  and  processes  of  shriveling,  and  especially  increase 
in  consistency,  size,  and  diameter.  The  looser  the  abdominal  in- 
teguments, and  the  more  completely  the  condition  of  enteroptosis 
is  developed,  the  more  favorable  are  the  conditions  for  palpation. 
If  the  kidney  can  not  be  palpated  when,  the  patient  is  in  the  dorsal 
position,  we  have  frequently  succeeded  in  palpating  it  by  placing 
the  patient  on  her  hands  and  knees  in  bed.  The  examiner  stands 
on  the  left  side  of  the  bed  and  patient,  facing  the  head.  Both 
arms  are  passed  around  the  patient's  body;  the  right  hand  is  in- 
serted beneath  the  lower  edge  of  the  liver  while  the  left  seeks  to 
meet  it  by  pressure  from  a  point  about  two  inches  above  the 
umbilicus. 

Gastroptosis. — Diseases  of  the  stomach  are  frequently  con- 
nected with  dislocation  and  movability  of  the  kidney.  Ewald  and 
others  are  of  the  opinion,  supported  by  observation  of  numerous 
successive  cases,  that  the  frequency  of  gastrectasia  with  dislocation 
of  the  right  kidney  was  due  always  to  an  etiological  connection.  The 
view  taken  by  Quincke,  Nothnagel,  and  Leube  is  that  both  patho- 
logical processes  occur  indeed  very  often  side  by  side,  without  any 
causal  connection  necessarily  existing  between  them.  The  changes 
of  position  (after  descent)  of  the  stomach  in  consequence  of  so- 
called  enteroptosis  and  dislocation  of  the  right  kidney,  are  not  the 


6l2  EXTEROPTOSIS GASTROPTOSIS. 

classic  gastrectasias  which  develop  in  consequence  of  mechanical 
obstructions  at  the  pylorus  (new  formations,  cicatrices  of  ulcers, 
distortions  in  consequence  of  adhesions,  compression,  obliteration, 
kinking,  etc.,  page  231  of  the  Proceedings  of  the  German  Congress 
for  Internal  Medicine,  1887),  but  consist  in  the  insufificiency  of 
the-  pylorus,  with  deep  location  and  dilatation  of  the  stomach, 
because  the  pylorus  and  the  duodenum  frequently  retain  a  normal 
position.  If  one  does  not  take  into  account  the  gastrectasias 
which  are  the  result  of  mechanical  causes,  there  still  remains  a 
very  large  number  of  functional  disturbances  of  the  stomach, 
which  lead  further  to  insufficiency  of  the  musculature  and  to  dila- 
tation and  low  position  of  the  organ.     To  this  class  are  assigned: 

1.  Disease  of  the  musculature  of  the  stomach  in  consequence  of 
protracted  chronic  gastritis. 

2.  Excessive  exertion  of  the  stomach  in  consequence  of  too 
much  and  unsuitable  indigestible  food. 

3.  Abnormally  slow  peristalsis  with  retention  of  food,  as  well 
as  the  abnormal  decomposition  of  the  retained  ingesta,  with  exces- 
siv^e  formation  of  gases. 

As  a  result  of  these  various  chronic  pathological  conditions  of 
the  stomach,  each  of  which  singly  forms  only  a  link  in  the 
whole  chain,  a  dilatation  of  the  stomach  with  attenuation  of  the 
walls  finally  develops,  and  later  a  sinking  down  of  the  organ  and 
descent  of  the  right  kidney,  with  abnormal  movability.  The 
function  of  the  stomach  is  seriously  injured  in  many  directions, 
especially  the  *  motor  power,  which  under  some  circumstances 
ceases  entirely. 

Litten  states  that  he  has  observed  a  great  number  of  individuals, 
especially  females,  where  one  could  recognize,  even  six  or  seven 
hours  after  taking  a  cup  of  milk  or  coffee,  a  very  distinct  and  wide- 
spread splashing  sound,  reaching  down  below  the  navel. 

In  such  individuals,  who  had,  under  the  supervision  of  the  physi- 
cian, taken  200  gm.  of  milk  and  coffee  mixed  at  seven  o'clock  in 
the  morning,  and  were  then  kept  under  constant  observation,  during 
which  they  took  in  absolutely  no  liquids,  there  could  still  be  heard 
a  loud  splashing  between  two  and  three  in  the  afternoon,  and  by 
means  of  the  siphon  170  gm.  of  liquid  were  recovered.  Such 
conditions  (called  by  the  French  "  dyspepsie  des  liquids  ")  concern 
only  liquid  food,  while  solid  foods  are  digested,  though  much 
more  slowly  than  normally.     It  was  thus  possible  to  effect  a  nearly 


PATHOGENESIS    OF    GLENARD's    DISEASE.  613 

normal  digestion  of  discs  of  albumin  placed  in  the  gastric  juice 
pumped  out  of  the  stomach.  These  observations  of  Litten  are 
more  intelligible  in  the  light  of  von  Mehring's  experiments  (see 
part  first),  according  to  which  it  is  certain  that  no  absorption  of 
water  takes  place  from  the  stomach  even  normally  ;  and  for  the 
resorption  of  substances  that  can  be  taken  up  by  the  mucosa,  a 
return  secretion  of  liquid  takes  place  from  the  mucosa  into  the 
stomach.  So  that  it  sometimes  happens  that  after  six  or  eight 
hours  more  liquid  is  drawn  out  of  the  stomach  than  was  ingested. 
The  digestive  power  varies  in  these  cases  with  the  state  of  HCl ; 
it  may  be  fairly  good  and  it  may  be  entirely  absent.  There  are 
undoubtedly  cases  of  gastroptosis  in  which  the  dislocated  stomach 
functions  normally. 

The  complexity  of  symptoms  which  lies  at  the  bottom  of  the  so- 
called  Glenard's  disease  is  so  frequently  traced  to  nervous  influ- 
ences exclusively,  that  it  seems  worth  the  while  to  look  for  a  dis- 
tinct pathological  substratum  for  the  disease.  Glenard  believes  he 
has  discovered  it  in  the  primary  lowering  of  the  flexura  coli  dextra. 
This  flexure,  he  argues,  may  sink  by  the  giving  way  of  the  naturally 
weak  ligamentum  coli  hepaticum.  The  transverse  colon  is  thus 
pushed  out  of  place,  and,  instead  of  running  transversely  to  the 
descending  colon,  it  now  ascends  diagonally  from  the  lower  right 
to  the  upper  left  part  of  the  abdomen.  In  place  of  the  junction 
characterized  by  the  ligamentum  pylori  coHcum,  there  arises  a 
kinking,  with  consequent  obstruction  to  the  course  of  the  feces, 
etc.  Beyond  this  obstruction  the  colon  contracts  its  walls,  be- 
comes thickened,  and  it  can  be  palpated  as  a  rigid  cord,  which 
Glenard  calls  the  "  corde  colique  transverse^  At  the  same  time 
a  downward  distortion  of  the  stomach  occurs,  sinking  of  the 
mesentery,  and  sometimes  a  nephroptosis  or  hepatoptosis,  or, 
in  one  word,  a  displacement  of  all  of  the  abdominal  organs. 
Ewald  has  questioned  the  frequency  of  splanchnoptosis,  as  given 
by  Glenard,  and  does  not  consider  his  diagnostic  signs  for  enterop- 
tosis  sufficient.  The  pulsations  of  the  aorta,  and  the  feeling  of 
the  transverse  colon,  which  the  latter  considered  characteristic 
signs,  Ewald  replaced  by  better  indications,  such  as  injection  of  air 
into  the  stomach  and  colon.  Further,  Ewald  does  not  agree  with 
Glenard  concerning  the  explanation  of  the  manifold  complaints  ;  he 
does  not  trace  them  back  to  the  mechanical  or  stenotic  phenomena, 
but  to  reflex,   torsional  phenomena   and  to   venous    stases.     The 


6l4  ENTEROPTOSIS GASTROPTOSIS. 

"  corde  coliqiie  transverse,"  he  argues,  is  nothing  else  but  the  pan- 
creas, which  can  be  palpated  through  a  lean  abdominal  integument. 
But  essentially  he  recognizes,  with  Glenard,  Cuilleret,  and  other 
French  authors,  and  with  the  German  Chlapowski  (the  only  author 
who  had,  up  to  the  date  of  Glenard's  publication,  written  about  the 
disease),  that  enteroptosis  is  a  genuine,  characteristic,  "  clinical 
entity." 

The  displacements  of  the  intestines,  which  arise  through  circum- 
scribed peritonitis,  through  obstruction  of  the  feces,  etc.,  were 
described  by  Virchow  as  early  as  1853.  Glenard  and  Ewald  have 
made  reference  to  the  entirely  uncomplicated,  one  might  say  the 
purely  gastric  and  intestinal,  cases. 

Landau  does  not  think  it  correct  to  be  content  with  the  diagnosis 
of  the  movable  kidney,  floating  liver,  and  kinking  of  the  transverse 
colon,  but  he  demands  that  the  etiological  diagnosis  be  also  given 
in  order  not  to  come  to  the  incorrect  conclusion  that  we  have  to 
do  with  independent  diseases.  Enteroptoses,  etc.,  are  secondary 
states  and  should, for  diagnosis  and  treatment,  be  taken  in  the  same 
way  as  roseola  with  typhus  or  syphilis,  in  which  one  is  certainly 
not  content  to  diagnose  roseola,  but  adds  typhus  or  syphilis  with 
roseola. 

Now,  which  are  the  diseases  that  cause  a  sinking  of  one  or 
more  of  the  abdominal  organs?  All  those  which  absolutely  or 
relatively  increase  the  capacity  of  the  abdomen,  and  thus  allow 
the  large  intestine,  fastened  by  the  relatively  long  mesocolon,  to 
sink,  according  to  its  weight.  The  slightest  or  first  degree,  for 
instance,  may  be  said  to  exist  where  we  meet  with  a  light  inguinal, 
femoral,  or  umbilical  hernia.  In  this  case  all  the  intestines  not  in 
the  hernial  sac  may  sink  through  pulling  and  dragging.  Since  the 
portions  of  the  intestines  which  were  formerly  in  the  peritoneal 
cavity  have  come  out,  the  capacity  of  the  abdomen  has  been  rela- 
tively increased. 

It  is  true,  splanchnoptosis  is  not  a  necessary  consequence  of 
large  ruptures.  Where  the  elasticity  and  contracting  power  of  the 
abdominal  integuments  are  very  great,  they  may  counteract  the 
increase  in  volume  by  tonic  contractions.  A  number  of  cases  are 
reported  in  which  almost  all  the  intestines  lay  in  ruptures,  and  in 
spite  of  this  the  kidney,  liver,  and  uterus  were  approximately  in 
normal  positions.  The  abdominal  integuments  were  contracted 
tightly  inward  and  were  concave  (Landau), 


CAUSE  AND  EFFECT  IN  SPLANCHNOPTOSIS.  615 

Of  far  greater  importance  for  the  origin  of  all  kinds  of  enterop- 
toses  is  a  second  great  category  of  diseases,  namely,  all  wasting 
diseases,  which  produce  a  quick  consumption  of  the  fat  of  the  body 
and  also  disturbances  in  the  nutrition  of  the  abdominal  integu- 
ments. Thus,  after  typhoid  fever,  scarlet  fever,  and  other  infectious 
diseases,  we  may  easily  recognize  splanchnoptoses  of  all  kinds, 
such  as  dislocation  of  the  kidneys  and  of  the  liver,  etc.  It  is  evident 
that  the  transverse  colon  must  be  lowered  also  when  the  liver  and 
kidney  can  be  felt  to  have  descended,  for  the  transverse  colon,  lying 
under  these  organs  and  connected  with  them  directly  and  indi- 
rectly, can  not  retain  its  position  under  these  conditions.  To  prove 
the  descent  of  the  transverse  colon  in  such  cases,  the  method  of 
the  injection  of  air  into  the  stomach  and  into  the  rectum  (Ewald) 
is  not  always  necessary,  nor  the  very  doubtful  result  of  direct 
palpation  of  the  transverse  colon,  as  given  by  Glenard. 

Chronic  diseases,  such  as  phthisis,  produce  exactly  the  same 
efifect  as  acute  diseases,  and  Landau  holds  that  primary  nervous 
dyspepsia,  primary  chronic  gastritis,  duodenitis,  etc.,  are  fre- 
quently not  the  result  of  enteroptosis,  but,  by  means  of  the 
disappearance  of  fat  and  weakening  of  the  abdominal  integu- 
ments, causes  of  it.  In  individuals  which  we  may  examine  to-day, 
and  in  whom  we  can  prove  no  sinking  of  the  liver  and  kidney,  if 
they  should  acquire  an  ulcer  of  the  stomach  or  nervous  dyspepsia, 
with  disturbances  of  nutrition,  we  may  be  able  to  show  prolapsus  of 
the  liver  or  kidney  later  in  the  course  of  the  disease. 

Among  the  patients  observed  by  us, — sufferers  from  disturbances 
of  nutrition,  nervous  dyspepsia,  emaciation,  etc., — in  which  the 
splanchnoptoses  mentioned  were  demonstrated,  there  were  surely 
many  cases  in  which  the  disturbances  of  nutrition  caused  the 
ptoses,  and  not  the  reverse. 

Relaxation  of  the  abdominal  muscles  with  or  without  pendulous 
abdomen  is  a  frequent  cause  of  splanchnoptosis.  Sinking  of  the 
kidneys  and  liver  develops  in  women  from  whom  large  ovarian 
tumors  or  myomata  have  been  removed  by  laparotomy.  Other 
cases  of  pendulous  abdomen  are  acquired  by  repeated  births,  fol- 
lowing close  on  one  another,  and  by  unsuitable  treatment  during 
confinement. 

Similarly,  splanchnoptoses  will  appear  in  individuals  who  suffer 
from  ascites,  and  who  have  been  punctured  repeatedly,  and  in  whom 
the  abdominal  muscles  have  finally  become  paretic  on  account  ofab- 


6l6  ENTEKOPTOSIS GASTROPTOSIS. 

normal  fullness  and  distention.  The  typical  form  of  pendulous  abdo- 
men does  not  always  arise  in  these  cases.  It  suffices  that  the  support 
of  the  abdominal  viscera,  which  is  formed  by  the  abdominal  integu- 
ments, becomes  insufficient ;  then  the  intestines  follow  the  law 
of  gravitation  and  descend  the  length  of  their  mesenteries,  and 
when  the  abdominal  integuments  have  become  distended  and  in- 
elastic, the  peritoneal  folds  of  the  liver  and  kidney  relax  also,  and 
these  follow  the  law  of  gravity  and  sink  because  one  of  their  main 
supports,  namely,  the  intestinal  mass,  has  been  withdrawn.  That 
which  is  principally  and  etiologically  of  prime  importance  in  these 
particular  cases,  therefore,  is  not  the  sinking  of  the  transverse 
colon,  but  disease  of  the  abdominal  integuments. 

In  a  large  number  of  splanchnoptoses  we  have  had  the  experience 
that  the  determination  of  the  etiological  factor  is  of  the  greatest 
importance  in  the  treatment.  Floating  kidneys  were  for  a  time 
ignored,  and  then  again  were  considered  a  terrible  disease,  danger- 
ous to  life.  There  was  a  time — and  it  has  not  been  so  very  long 
ago — when  the  movable  kidney  was  regarded  as  an  indication  for  its 
removal,  and  it  was  in  fact  extirpated.  This  was,  in  a  certain  sense, 
a  consequence  of  the  opinion  that  the  movable  kidney  as  such  was 
a  disease  siii generis,  or,  to  speak  with  Glenard,  a  "  morbid  entity," 
which  made  life  a  burden.  It  could  also  happen  similarly  with  the 
prolapsed  transverse  colon,  if  we  take  its  case  as  a  morbid  entity  and 
accuse  it  of  causing  the  host  of  nervous  symptoms,  etc.  It  is  there- 
fore not  only  scientific,  but  also  practical,  to  combat  this  idea  of  a 
"  morbid  entity,"  and  to  oppose  the  hypothesis  that  enteroptosis  is 
an  individual  disease.  Of  course,  we  do  not  wish  to  deny  that  the 
falling  of  the  intestine  and  the  abdominal  organs  may  bring  un- 
pleasant circumstances  with  it,  or,  to  be  more  exact,  that  in  indi- 
viduals who  have  a  floating  kidney  (an  enteroptosis)  one  observes 
manifold  and  unpleasant  symptoms,  among  which  those  of  nervous 
dyspepsia  are  most  marked.  But  we  must  again  emphasize  that  it 
is  not  the  sinking  of  one  organ,  but  a  more  general,  more  important 
state  which  causes  this  disease  with  all  its  complications, — the  falling 
of  the  intestine,  as  well  as  a  host  of  nervous  complaints,  venous 
obstruction  and  the  like, — namely,  the  relaxation  of  the  abdominal 
integuments,  the  decrease  in  irritability  and  the  attenuation  of  the 
muscles,  the  loss  of  elasticity  of  the  skin  and  of  the  peritoneum, 
etc.  Naturally,  from  these  secondary  states  caused  by  pen- 
dulous abdomen,  further  very  severe  diseases  may  sometimes  arise. 


LOCATIONS    OF    INTESTINAL    STENOSES.  617 

There  are   five   places    especially  at  which    stenosing  phenomena 
may  appear  through  temporary  kinking  : 

(i)  At  the  pyloric  part  of  the  stomach,  or  where  the  duodenum 
passes  over  from  the  superior  horizontal  part  into  the  vertical 
portion,  which  is  tightly  joined  to  the  spinal  column. 

(2)  At  the  entrance  of  the  jejunum  into  the  duodenum,  at  the 
duodenojejunal  flexure  (E.  C.  Perry  and  L.  E.  Shaw,  "  Diseases 
of  the  Duodenum,"  Guy's  Hospital  Reports,  1893,  p.  171). 

(3)  At  the  transition  of  the  small  intestine  into  the  fixed  portion 
of  the  cecum. 

(4)  At  the  transition  of  the  transverse  colon  into  the  descending 
colon,  which  is  comparatively  tightly  fixed  at  the  posterior  lateral 
abdominal  wall,  and  is  further  attached  high  up  into  the  left 
hypochondrium  by  the  phrenocolic  ligament  (Phoebus).  The  left 
flexure  of  the  colon  normally  forms  a  right  angle  which,  however, 
becomes  an  acute  angle  with  pendulous  abdomen. 

(5)  In  some  cases,  when  the  hepatic  flexure  of  the  colon  has 
not  sunk,  stenoses  may  develop  in  it  at  a  corresponding  place,  as 
described  in  No.  4  (Landau,  on  "  Pendulous  Abdomen,"  p.  82,  et  seg.). 

The  floating  kidney  is  to  be  put  semiotically  on  a  level  with 
enteroptosis  ;  it  is  not  a  disease  sui  generis. 

While  the  sinking  of  the  kidney  was  formerly  regarded  as  a  rare 
disease,  it  is  now  recognized  universally  as  a  very  frequent  condition. 
Sufficient  emphasis  has  already  been  laid  on  the  possible  sources  of 
error  in  the  diagnosis.  A  surprisingly  large  number  of  movable 
kidneys  are  diagnosed  by  otherwise  very  skilful  diagnosticians, 
when  they  are  really  dealing  with  cases  of  descent  of  the  liver. 
The  best  way  to  palpate  the  kidney  is  by  the  bimanual  method 
of  palpation  given  by  Jenner  and  Freund.  All  later  contribu- 
tions to  the  subject  by  other  authors  have  added  nothing  essen- 
tially new  to  the  bimanual  method.  If  we,  therefore,  regard  the 
movable  kidney,  just  as  the  sinking  of  the  intestines  and  of  the 
liver,  to  a  certain  degree  as  a  secondary  consequence  of  the  relaxa- 
tion of  the  abdominal  integuments,  we  must,  however,  admit  that 
the  movable  kidney  on  its  part,  though  caused  secondarily,  may 
itself  often  be  the  cause  of  very  severe  diseases. 

The  dangerous  sequences  of  floating  kidney  are  hydronephrosis, 
intermittent  hydronephrosis,  and  incarceration  of  the  kidney  (first 
described  by  DittI).  This  dangerous  condition  is  largely  ascrib- 
able  to  compression  of  the  renal  veins. 


6l8  ENTEROPTOSIS GASTROPTOSIS. 

Landau  agrees  with  Glenard  in  recommending  almost  verbatim 
the  same  method  of  treatment  which  he  has  used  for  enterop- 
tosis  and  pendulous  abdomen.  It  is  very  simple,  and  consists  in 
strengthening  the  lax  abdominal  integuments,  and  in  providing, 
to  a  certain  extent,  artificial  abdominal  integuments.  Bandages 
are  useful  in  the  treatment  of  floating  kidney.  The  abdominal  band- 
ages suggested  by  Landau,  Ewald,  and  Glenard  do  not  differ 
materially.  A  large  number  of  the  patients  suffering  from  movable 
kidney  are  still  tortured  by  the  use  of  bandages  with  padded  plates, 
which  are  supposed  to  keep  the  kidney  fixed  after  replacement, 
which  they  rarely  do. 

Diagnosis. — It  is  evident  that  movable  kidney  may  be  undoubt- 
edly recognized  in  all  cases  where  we  can  fixate  it  between  the  fingers 
and  can  thus  determine  exactly  its  entire  configuration.  Secondly, 
the  diagnosis  is  comparatively  simple  in  those  cases  where  we  in- 
deed may  not  determine  the  configuration,  where  we  discern  only  a 
smooth  movable  body,  often  movable  only  within  narrow  limits, 
but  where  we  are  aided  by  the  communications  of  the  patient,  that 
suddenly,  after  bodily  exertion,  this  body  was  felt.  But  there  are 
cases  where  this  information  of  the  patient  is  lacking,  where  we 
can  no  longer  make  the  diagnosis  from  palpation  with  certainty, 
and  here  mistakes  are  possible.  The  chief  error,  according  to  our 
experience,  is  that  one  has  to  do  with  a  small  lower  part  of  the 
liver,  separated  from  it  by  a  strong  furrow  due  to  compression, 
which  part,  on  account  of  the  depth  of  the  furrow,  seems  to  be 
movable.  Guttmann  has  seen  such  cases  repeatedly  in  autopsies, 
which  during  life  were  regarded  as  movable  livers.  Osier  ("  Lec- 
tures on  the  Diagnosis  of  Abdominal  Tumors,"  p.  97)  gives  an 
illustration  of  a  tongue-shaped  prolongation  of  the  anterior  mar- 
gin of  the  right  lobe  with  the  gall-bladder  projecting  below  it. 

Since  by  means  of  the  bimanual  examination,  which  has  been 
described  in  detail,  we  are,  at  least  in  a  number  of  cases,  able 
to  feel  the  lower  end  of  the  right  kidney  during  inspiration,  it  is 
not  difficult  to  exclude  movable  kidney.  And  since  movability 
occurs  most  frequently  with  the  right  kidney  in  more  than  80  per 
cent,  of  the  cases,  therefore,  by  finding  the  right  lower  edge  of  the 
kidney  in  bimanual  palpation,  the  error  of  mistaking  a  portion  of  the 
liver  (separated  from  it  by  a  furrow)  for  the  kidney  might  be  avoided. 

Proving  by  means  of  percussion  that  the  kidney  is  not  in  the 
place  where  it  belongs,  is  very  unsatisfactory.     It  seems,  indeed,  in 


FKEOL'ENXY    OF    DISLOCATED    KIDNEY.  619 

some  cases,  that  the  dullness  is  less  on  that  side  where  the 
kidney  is  wanting,  than  on  the  opposite  side  where  the  kidney 
is  present.  But  in  most  cases  of  movable  kidney  there  was  no 
difference  in  the  resonance  in  the  region  of  the  loins  on  either 
side.  We  therefore  attach  no  value  to  the  results  of  percussion 
in  dislocated  kidney,  and  the  same  opinion  of  the  use  of  percussion 
holds  good  in  diseases  of  the  kidney  in  general.  Only  in  isolated 
circumstances  it  may  aid  the  other  methods  of  examination, — £■  g-, 
with  great  swelling  of  the  kidneys, — but  in  most  cases  percussion 
of  the  kidneys  is  entirely  worthless,  and  hence  it  is  not  considered 
a  diagnostic  method. 

Frequency  of  Dislocated  Kidney. — The  statements  of  various  clin- 
icians concerning  the  frequency  of  floating  kidney  vary  consider- 
ably. Lindner  stated  that  it  was  the  most  frequent  abnormality  of 
the  female  body,  and  that  one  woman  in  five  to  seven  was  afflicted 
with  the  trouble.  Edebohls  gives  i8  per  cent.,  Mathieu  27.1  per 
cent.,  Fischer-Benzon  17  to  22  per  cent.,  John  Schmitt  10  per 
cent.  (New  York,  Mediz.  Monatssclirift,  March,  1891).  Ludwig 
Knapp  ("  Wanderniere  bei  Frauen,"  Berlin,  1896)  gives  five 
per  cent. 

As  far  as  our  clinical  material  permits  us  to  judge  (148  exami- 
nations from  hospital  and  private  practice),  the  rate  for  Baltimore 
is  six  per  cent.  The  right  kidney  is  dislocated  more  frequently 
than  the  left,  the  proportion  being  15  to  i,  and  bilateral  dislocation 
was  found  only  once. 

Reversal  of  the  Location  of  the  Viscera  [Situs  visceruvi  inversus). — 
In  this  state  the  stomach  lies  normally  on  the  right  side,  the  liver 
on  the  left.  The  site  of  all  of  the  viscera  is  exactly  reversed  ; 
there  is  a  situs  inversus,  however,  in  which  the  heart  is  found  in 
the  normal  position,  at  the  same  time  the  location  of  all  other 
organs  is  reversed. 

Vertical p.ositiou  of  the  stomacli  is  an  anomaly  frequently  associ- 
ated with  atony,  which  is  attributed  to  tight  lacing.  It  becomes 
important  clinically  only  when  the  motor  function  is  interfered  with, 
in  which  case  the  treatment  is  the  same  as  that  given  for  motor  in- 
sufficiency. The  diagnosis  of  vertical  stomach  should  present  no 
difficulties  when  the  methods  stated  on  pages  97  to  104  are  employed. 

Ewald's  assertion  of  the  extraordinary  frequency  of  movable 
kidney  is  the  more  astonishing  because  in  autopsies  one  does  not 
often  find  movable  kidneys.     Guttmann  in  reporting  his  experience, 


620  ENTEROPTOSIS GASTROPTOSIS. 

resting  upon  about  8000  autopsies  at  Berlin,  which  for  the  most 
part  he  himself  noted  down,  stated  that  in  these  autopsies  the 
floating  kidney  was  not  frequent.  His  experience  agrees  with  that 
of  the  pathological  institute  of  the  Charite,  Berlin.  Landau,  in  his 
monograph  on  the  floating  kidney,  states  that  in  the  Charite 
floating  kidneys  were  found  very  rarely  at  autopsies.  We  may 
add,  however,  that  in  a  horizontal  position  the  movable  kidney 
sinks  back  to  its  normal  position,  and  is,  therefore,  liable  to  be 
overlooked  in  the  necropsy  ;  but  the  movability  must  persist,  and 
this  must  attract  our  attention  when  the  kidney  is  taken  out.  An 
experienced  dissector  will  notice  at  once  in  taking  out  the  kidney 
whether  it  is  normally  fixed  or  whether  it  is  movable  at  the  place 
in  question. 

Symptoms  of  Gastroptosis. — The  symptoms  are  brought  on 
by  the  gastric  and  intestinal  atony  and  the  mechanical  disturbances 
caused  by  the  descent  of  the  organ.  We  have  observed  a  number 
of  cases  of  gastroptosis  that  presented  no  digestive  symptoms  what- 
ever. The  dyspeptic  symptoms  that  are  most  common  are :  pres- 
sure, fullness,  distention,  and  pain  (gastralgia),  coming  on  at  irreg- 
ular intervals,  and  independently  of  the  digestive  act  or  the  quality 
and  quantity  of  the  food.  A  sensation  of  heat  or  burning  at  or 
below  the  umbilicus  is  at  times  described.  Eructations,  nausea, 
vomiting,  and  pyrosis  maybe  complained  of  Chronic  constipation 
is  a  typical  accompaniment ;  flatulence  and  occasional  attacks  of 
diarrhea  alternate  with  constipation. 

When  there  is  an  evident  coloptosis,  a  very  stubborn  membran- 
ous dysentery  is,  as  a  rule,  present,  being  no  doubt  caused  by 
abnormal  kinking  and  stenosing  flexures  in  the  course  of  the  large 
intestine. 

The  quantity  of  the  'urine  may  be  very  variable  and  depends 
upon  the  permeability  of  the  ureters.  Absolute  obliteration  of  the 
ureter  by  kinking  may  produce  oliguria  or  anuria,  which  may  be 
followed  by  profuse  urination  when  the  ureter  becomes  straight- 
ened. 

Nervous  Symptoms. — The  typical  clinical  picture  of  aggravated 
neurasthenia  is  frequently  associated  with  these  cases.  The  mani- 
fold pains  complained  of  during  bodily  exertion  are  referable  to 
drawing  and  tugging  upon  the  nervous  apparatus  supplying  the 
dislocated  organs.     Intense  lumbago  is  a  most  frequent  sign. 

According  to  Kuttner,  Litten,  and  Ewald,  four  distinct  phases  or 


PROLAPSUS    OF    THE    SPLEEN,    LIVER,    AND    COLON.  62 1 

degrees  of  nephroptosis  may  be  differentiated  by  palpation:  (i)  A 
respiratory  movability  without  dislocation.  (2)  Respiratory  mov- 
ability  with  slight  anterior  dislocation, — one-third  to  two-thirds  of 
the  kidney  can  be  palpated  ;  this  is  termed  a  "  dislocation  of  the 
first  degree."  (3)  Respiratory  movability  with  close  approximation 
to  the  anterior  abdominal  wall.  The  kidney  is  palpable  in  its 
entirety,  and  can  be  easily  moved  about;  this  is  termed  a  "  disloca- 
tion of  the  second  degree."  (4)  The  dislocated  kidney  is  firmly 
adherent  in  its  abnormal  position. 

The  spleen  has  been  very  rarely  found  dislocated  in  splanchnop- 
tosis, Glenard  having  observed  splenoptosis  only  twice  in  148  cases. 

Hepatoptosis  can  be  recognized  by  a  lowering  of  the  area  of 
hepatic  dullness.  There  are  several  degrees  of  liver  displace- 
ment: (ij  A  portion  of  the  liver  projects  beyond  the  arch  of  the  ribs 
into  the  abdomen,  and  the  upper  border  is  correspondingly  lower. 
(2)  The  larger  portion  of  the  liver  projects  into  the  abdomen  ;  the 
liver  dullness  above  the  edge  of  the  ribs  is  reduced  to  a  narrow 
zone  or  entirely  absent.  (3)  The  entire  liver  is  located  within  the 
lower  abdomen. 

Coloptosis. — Descent,  displacement  with  consequent  local  stenosis, 
and  dilatation  of  portions  of  the  colon,  can  only  be  recognized  by 
distending  the  colon  with  air  or  water.  The  air  is  usually  forced 
in  through  a  long  colon  tube  (Langdon)  by  means  of  a  double  bulb 
pump,  or  600  c.c.  to  one  liter  of  warm  water  are  gradually  allowed  to 
run  in  under  gentle  pressure.  Normally,  a  distended  area  is  palp- 
able and  even  visible  two  or  three  inches  above  the  umbilicus;  the 
ascending  and  descending  colon  can  be  recognized  as  two  arching 
elongated  prominences  about  three  inches  to  either  side  of  the 
umbilicus.  When  the  colon  is  prolapsed,  the  transverse  portion  is 
found  touching  at  the  symphysis  pubes,  or  even  within  the  pelvis. 
We  have  frequently  observed  that  a  prolapsus  of  the  colon  was 
recognizable  by  the  distention  which  had  occurred  through  gaseous 
fermentation,  and  artificial  distention  was  unnecessary.  When  a 
prolapsed  colon  is  distended  with  warm  water  it  changes  its  posi- 
tion with  the  attitude  of  the  patient.  Thus  a  colon  that  rests  on 
the  symphysis  will  rise  to  its  normal  location  when  the  pelvis  is 
elevated  and  the  thorax  depressed.  If  this  does  not  occur,  the 
colon  is  adherent  in  its  abnormal  location. 

Electrodiaphany  is  an  excellent  method  of  diagnosing  the  course 
and   location    of  the   colon.     W'e   have  frequently  used  it  for  that 
41 


622  ENTEROPTOSIS GASTROPTOSIS. 

purpose  (see  pp.  103  and  104),  for  which  it  is  as  convenient  and 
accurate  as  for  recognizing  gastroptosis. 

Gastroptosis  can  occasionally  be  recognized  by  inspection ;  the 
methods  described  in  chapter  xi,  pp.  97—104,  if  systematically  car- 
ried out,  can  leave  no  possible  doubt  regarding  the  existence  of 
this  dislocation.  The  differentiation  between  prolapsus  and  dilata- 
tion is  facilitated  by  electrodiaphany.  If  the  stomach  is  dilated,  not 
prolapsed,  the  transilluminated  area  will  exhibit  respiratory  mova- 
bility.  Boas  and  others  have  observed  gastric  dilatation  in  con- 
junction with  gastroptosis.  This  combination,  in  our  experience, 
is  very  rare.  Ewald,  Litten,  and  Bartels  assert  that  dilatation  of  the 
stomach  frequently  occurs  with  nephroptosis  or  hepatoptosis,  this  is 
not  confirmed  by  Boas  ;  myasthenia,  with  over-retention  and  stasis  of 
ingesta,  is  frequently  observed,  though  not  in  all  cases  of  prolapsus 
of  the  stomach.  But  we  agree  with  Boas  that  the  typical  clinical 
picture  of  classical  dilatation  is  rare  in  connection  with  gastroptosis. 

Analysis  of  the  gastric  contents  in  gastroptosis,  though  yielding 
no  practical  aids  to  diagnosis,  is  of  utility  in  selecting  a  proper  diet. 
The  results  of  such  chemical  analyses  are  variable. 

The  course  of  gastroptosis  is  a  protracted  and  generally  a  chronic 
one.  Great  feebleness,  abnormal  sensations  of  pain,  compression, 
or  of  cold  and  hot  aurae,  indisposition  to  exertion,  and  faintness  are 
among  the  most  common  symptoms  in  this  most  variable  clinical 
picture.  Severe  disturbances  of  nutrition  and  anemia  unfailingly 
appear  as  the  digestive  distress  continues. 

The  points  of  differentiation  between  falling  of  the  stomach  and 
dilatation  and  atony  have  been  considered  in  the  chapters  on  these 
diseases.  The  differential  diagnosis  between  the  symptoms  of 
gastroptosis  and  nervous  dyspepsia  is  difficult,  sometimes  requiring 
all  the  ingenuity  of  an  experienced  diagnostician.  This  is  prin- 
cipally because  the  symptoms  of  both  states  are  occasionally 
identical,  and  because  gastroptosis  is  often  associated  with  nervous 
dyspepsia.  The  state  of  the  peristalsis  is  normal  in  nervous  dys- 
pepsia, but  in  gastroptosis  there  is,  as  a  rule,  a  myasthenia,  with 
over-retention  of  ingesta. 

Treatment  of  Gastroptosis. — Prophylaxis. — The  frequency  of 
gastroptosis  and  enteroptosis  in  the  female  sex  demands  that 
the  physician  should  emphatically  oppose  tight  lacing,  or  any 
garment  that  constricts  the  waist;  the  dresses  should  be  so  con- 
structed as  to  be  .supported  from  the  shoulder.     We  have  already 


GYMNASTIC    PROPHYLAXIS.  623 

spoken  of  this  under  the  heading  of  acute  gastritis.  If  possible, 
the  modifications  in  dress  should  be  made  in  accordance  with  the 
rules  of  fashion.  It  will  do  no  good  to  oppose  the  unrestricted 
domination  of  this  tyrant  of  the  female  sex,  without  clear  indica- 
tions of  the  benefit  to  be  derived.  We  have  already  emphasized 
that  a  properly  constructed  corset  need  not  necessarily  work  harm, 
but  may  eventually  be  useful  by  the  support  it  gives  to  the  back 
and  breasts.  The  dresses  should,  then,  be  supported  from  the 
shoulders.  It  is  necessary  to  do  this  before  the  enteroptosis  is 
developed. 

The  relaxation  of  the  abdominal  muscles  must  be  prevented  by 
well-applied  bandages  used  after  confinements,  and  worn  for  several 
months.  The  bowels  must  be  kept  regular.  Massage,  electricity, 
and  cold-water  applications  may  contribute  to  a  vigorous  abdo- 
minal musculature,  but  the  most  effective  means  of  strengthenine 
the  abdominal  muscles,  and  one  which  we  do  not  find  considered 
in  the  text-books  on  the  subject,  are  abdominal  gymnastics. 

We  will  briefly  describe  two  of  the  most  practical  methods  of 
training  the  abdominal  muscles. 

IVo.  I. — The  patient  places  himself  on  a  couch,  or  on  a  blanket 
spread  on  the  floor,  clothed  simply  in  his  or  her  underwear ;  the 
hands  are  placed  at  the  side ;  the  exercise  begins  by  slowly  raising 
the  limbs  from  the  couch  to  a  vertical  position  in  the  air,  keeping 
them  there  for  thirty  seconds,  then  very  slowly  letting  them 
return  to  the  horizontal  position  of  rest.  The  secret  of  this 
maneuver  is  the  slow  execution  of  it.  With  one  hand  on  the  abdo- 
minal muscles,  the  patient  may  feel  the  tightening  and  rigidity 
which  occur  in  the  act  of  raising  the  limbs.  This  exercise  should 
be  repeated  ten  times. 

No.  2. — The  second  exercise  should  be  carried  out  in  the  follow- 
ing manner :  The  patient  places  himself  flatly  on  a  blanket  on 
the  floor,  with  his  feet  inserted  under  a  bureau  or  piece  of  heavy 
furniture  of  any  kind ;  both  hands  are  placed  steadily  at  the  side 
of  the  body.  The  patient  now  must  slowly  bring  the  trunk  of  his 
body  into  an  erect  position,  and  when  this  has  been  reached,  the 
trunk  is  just  as  slowly  replaced  to  a  position  of  rest  on  the  floor. 

Both  of  these  exercises  are  quite  similar;  in  No.  i  it  is  the  trunk 
which  is  fixed  and  the  lower  limbs  are  slowly  moved  up  and  down, 
and  in  No.  2  the  lower  limbs  are  fixed  and  the  trunk  is  moved  up 
and  down.     These  exercises   should   be   carried  out  systematically 


624  ENTEROPTOSIS GASTROPTOSIS. 

and  methodically  ten  times  every  morning  and  evening.  Sandovv's 
book  on  training  will  instruct  those  desiring  information  on  this 
very  useful  subject. 

Rapid  emaciation  must  be  avoided.  Physicians  are  nowadays 
frequently  consulted  by  thin  people  desiring  to  get  fat,  and  by  fat 
people  desiring  to  become  thin  in  the  most  convenient  manner. 
Rapid  falling-off  and  loss  of  fat,  when  undertaken  as  a  cure  for 
obesity,  is  in  our  experience  a  hazardous  undertaking.  The  fat  is 
not  only  lost  from  the  trunk  and  extremities,  but  the  internal 
organs  are  deprived  of  their  normal  incasing  and  imbedding  of 
fat,  which  constitutes  their  support,  so  that  cures  tending  to  reduce 
the  weight  of  the  body  should  only  be  conducted  under  the  super- 
vision of  a  capable  physician. 

The  Mechanical  Treatment. — The  mechanical  treatment  consists  in 
applying  a  properly  selected  and  adapted  abdominal  bandage.  There 
is  no  one  particular  bandage  that  will  suit  all  cases.  The  bandages 
should  have  their  main  support  and  resting-places  upon  the  crests 
of  the  ilium,  symphysis  pubes,  and  spinal  column.  From  here  the 
strength  of  the  bandage  is  secured  by  broad  pieces  of  metal  or 
whalebone  inserted  into  the  linen,  leather,  or  rubber  parts  of  the 
bandage.  These  bandages  must  be  fitted  to  the  nude  figure,  must 
fit  perfectly,  and  be  worn  day  and  night.  Boas  recommends  the 
bandage  of  Landau  and  Bardenheuer.  Prolonged  rest  in  a  hori- 
zontal position  on  the  back  favors  restitution  of  the  abdominal  vis- 
cera to  their  normal  position.  In  cases  of  great  weakness,  there- 
fore, with  emaciation,  the  Weir  Mitchell  rest  cure  is  one  of  the 
most  effective  means  of  treatment. 

Constipation  is  best  combated  by  proper  diet.  We  recom- 
mend compotes  of  fruit,  such  as  figs,  prunes,  apples,  pears,  plums, 
and  sweet  grapes.  Buttermilk  and  kefyr  favor  normal  evacuation. 
Sugar  of  milk,  oss  three  times  daily,  is  also  efficacious  (see  p.  236). 
As  gastroptosis  predisposes  to  dilatation,  it  may  occur  that  the 
foods  are  retained  an  abnormally  long  time  within  the  stomach.  In 
these  cases  lavage  will  be  indispensable. 

When  the  symptoms  of  atony  and  motor  insufficiency  are  pro- 
nounced, local  intragastric  douches  with  alternating  cold  and  warm 
water  are  very  effective  in  restoring  partial  tonicity  to  the  muscular 
walls.  Treating  the  abdominal  muscles  by  massage  and  the  fara- 
dic  current  is  of  some  utility  in  patients  that  are  too  feeble  to 
undergo  the  abdominal  gymnastic  training.     These  means  of  treat- 


DIETETIC    AND    MEDICINAL    TREATMENT.  625 

ment  may  be  applied  also  in  those  cases  that  have  not  the  will- 
power to  persist  in  such  abdominal  gymnastics,  but  electricity  and 
massage  can  not  effect  the  permanent  improvement  which  we  have 
observed  as  a  result  of  abdominal  gymnastics. 

Floating  kidneys,  according  to  Bachmeier  [IVien.  vied.  Presse, 
1 89 1,  Nos.  19  and  20),  may  be  replaced  best  in  the  following 
manner:  The  patient  is  placed  on  his  back  in  bed,  the  physician 
taking  a  chair  facing  him  ;  both  hands  are  placed  on  the  right  side 
of  the  patient,  under  the  anterior  arch  of  the  ribs;  the  hands  are 
then  pressed  gently  and  firmly  toward  the  posterior  and  superior 
parts  of  the  abdomen.  While  this  pressure  is  exerted,  the  finger- 
tips must  make  constant  shaking  and  trembling  motions. 

Diet. — In  enteroptosis  and  gastroptosis  the  diet  should  be  as 
nourishing  as  possible,  and  adapted  to  the  state  of  motility  and 
secretion.  If  the  condition  of  the  digestive  organs  will  permit, 
attempts  should  be  made  at  increasing  the  adipose  tissue.  Dis- 
tinct diseases  of  the  gastric  mucosa  contraindicate  a  large  food 
supply.  Experience  has  taught  us  that  one  of  the  best  treatments 
for  floating  kidney  is  that  which  causes  an  increased  deposition 
of  fat.  Fat  is  best  introduced  in  diet  in  the  form  of  fresh  butter, 
rich  gravies,  and  cream.  For  further  particulars  of  nourishing 
diet  we  refer  to  the  section  on  dietetics.  In  our  sanitarium  for 
digestive  diseases,  we  have  found  the  schedule  on  pp.  240  and  241 
useful  in  nephroptosis. 

Medicinal  Treatmeni. — Medicines  are  sometimes  unavoidable 
for  the  treatment  of  constipation.  Our  favorite  remedy  for  this, 
where  it  becomes  necessary,  is  the  active  syrup  of  cascara  sagrada 
(Clinton  Pharm.  Co.),  or  large  colon  irrigations  with  warm  water 
which  will  also  benefit  the  membranous  colitis.  Where  patients 
can  take  it,  the  time-honored  castor  oil  is  a  good  and  harmless 
remedy.  Of  other  laxative  remedies,  we  favor  rhubarb,  mag- 
nesia, senna,  and  podophyllin.  Aloes,  jalap,  and  scamany  do  not 
act  well,  nor  do  the  very  drastic  purgative  waters,  such  as  the 
Hunyadi  Janos  and  Rubinat  Condal.  We  have  seen  more  lasting 
results  follow  a  persistent  use  of  Bedford  Magnesia  Springs  water, 
which  is  rather  mild  in  its  purgative  qualities. 

Glenard  recommended  magnesium  and  sodium  sulphate  to  com- 
bat the  effects  of  auto-intoxication,  but  Boas,  after  a  prolonged 
trial  of  these  remedies,  asserts  that  he  has  observed   detriment  to 


626  ENTEROPTOSIS — GASTROPTOSIS. 

result  from  them.     Our  formula  for   combating   auto-intoxication 
in  gastroptosis  is  the  following  : 

B.      Betanaphthol.  bismuth., 4.0  ^j 

Resorcin.   resublim. , 4.0  ^j 

Strychnin  sulphatis, 0.02        gi'-/3 

In  anacidity — achylia — dilute  HCl,  ^iv,  should  be  added. 

Elix.  gentianse, 180.0  f^^J-  '^''■• 

SiG. — One  tablespoonful  three  times  daily. 

In  addition  to  these,  the  salicylate  of  bismuth,  salicylic  acid, 
chloroform  water,  and  betanaphthol  have  been  recommended. 
They  are  made  more  efificacious  if  combined  with  strychnin  and  an 
adapted  diet. 

It  is  conceivable  that  methods  of  surgical  procedure  may  in 
future  be  devised  for  replacing  a  prolapsed  stomach,  by  attaching  it 
partly  to  the  diaphragm  and  partly  to  the  retroperitoneal  fascia  in 
such  a  manner  as  to  avoid  kinking  or  stenosis. 

BIBLIOGRAPHY  ON  GASTROPTOSIS  AND  ENTEROPTOSIS. 

1.  Boas,  "  Ueber  die  Bestimmung  der  Lage  und  Grenzen  des  Magens  durch 
Sondenpalpation,"  Cejitralbl.  f.  klin.  Med.,  1896. 

2.  Bourget,  "Ueber  dea  klinischen  Werth  des  Chemismus  des  Magens," 
Therap.  Monatshefte ,  1895. 

3.  Cuilleret,  "Etude  Clinique  sur  I'Enteroptose  ou  Maladie  de  Glenard," 
Gazette  des  Hopit.,  1888. 

4.  Czerny,  "  Zur  Prophylaxis  des  Hangebauches  der  Frauen,"  Centralbl.  f. 
Gynakologie,  1886. 

5.  Dehio,  "  Zur  physikalischen  Diagnostik  der  mechanischen  Insufficienz 
des  Magens,"  VII  Congress  f.  innere  Med.,  1888. 

6.  Edinger,  "  Wanderniere,"  Eule7ibnrg  s  Real-Encyklop.,  2.  Aufl.,  xxi. 

7.  Ewald,  "  Ueber  Enteroptose  und  Wanderniere,"  Berl.  klin.  Wochenschr., 
1890. 

8.  Fleiner,  "  Ueber  die  Behandlung  der  Constipation  und  einiger  Dickdarm- 
affectionen  mit  grossen  Oelklystieren,"  Berl.  klin.  Wochenschr.,  1893. 

9.  Fleiner,  "Ueber  die  Beziehungen  der  Form- und  Lageveranderungen 
des  Magens  und  des  Dickdarms  zu  Functionsstorungen  und  Erkrankungen 
di\z'i,&x  Oxg'dsn.^''  Milnchener  med.  Wochettsckr.,  1895. 

10.  Gegenbaur,  "  Lehrbuch  der  Anatomic  des  Menschen." 

11.  Glenard,  "  Application  de  la  Methode  Naturelle  a  I'Analyse  de  la  Dys- 
pepsie  Nerveuse,"  Lyon  Med.,  1885;  "Enteroptose  et  Neurasthenie,"  Soc. 
Medic,  des  Hop.  de  Paris,  1886  ;  "  Expose  Sommaire  du  Traitement  de  I'Ente- 
roptose, Lyon  Med.,  1887,  etc. 

12.  Hertz,  P.,  "  Abnormitaten  in  der  Lage  und  Form  der  Bauchorgane  bei 
dem  erwachsenen  Weibe,"  Berlin,  1894. 


LITERATURE    OX    GASTROPTOSIS    AND    ENTEROPTOSIS.  62/ 

13.  Hilbert,  "  Ueber  palpable  und  bewegliche  Xieren,"  Deiiisches  Archiv  f. 
klin.  Med.,  1893,  Bd.  L. 

14.  Huber,  A.,  "  Beitrag  zur  Kenntniss  der  Enteroptose,"  Sonderabdr.  a.  d. 
Correspondenzbl.  f.  Schiveizer  Aerzte,  1895,  Nr.  11. 

15.  Israel,  "  Ueber  die  Palpation  gesunder  und  kranker  Nieren,"  Berl.  klin. 
Wochenschr.,  1889. 

16.  Kelling,  "  Ein  einfaches  Verfahren  zur  Bestimmung  der  ^lagengrosse 
mittelst  Luft,"  Deutsche  med.  Wochenschr.,  1892. 

17.  Kelling,  "  Physikalische  Untersuchungen  iiber  die  Druckverhaltnisse 
in  der  Bauchhohle,  sowie  liber  die  Vitalcapacitat  des  Magens,"  Leipzig,  1896. 

18.  Konig,  G.,  "  Chemische  Zusammensetzung  der  menschlichen  Xahrungs- 
und  Genussmittel,"  Berlin,  1889  und  1893. 

19.  Kussmaul,  "  Die  peristaltische  Unruhe  des  Magens,  nebst  Bemerkungen 
iiber  Tiefstand  und  Erweiterungen  desselben,"  etc.,  Volkma^in  s  Sa7nmlung 
klin.  Vortrage,  Nr.  181. 

20.  Kuttner,  "  Ueber  palpable  Xieren,"  Berl.  klin.  Wochenschr.,  1890. 

21.  Kuttner,  "  Einige  Bemerkungen  zur  elektrischen  Durchleuchtung  des 
Magens,"  Berl.  klin.  Wochenschr.,  1895. 

22.  Landau,  "  Die  Wanderniere  der  Frauen,"  Berlin,  1881. 

23.  Leo,  "  Diagnostik  der  Krankheiten  der  Bauchorgane,"  2.  Aufl.,  1895. 

24.  Leube,  "  Specielle  Diagnostik  innerer  Krankheiten,"  1891. 

25.  Litten,  "  Ueber  den  Zusammenhang  der  Magenerkrankungen  mit  Lage- 
veranderungen  der  rechten  Niere,"  Verhandlungen  des  Congresses  fiir  innere 
Medizin,  vi,  1897;  Ferner:  Berliner  med.  Gesellschaft,  Sitzung  vom  19.  Marz, 
1890,  Berl.  klin.  Wochenschr.,  1890,  Nr.  15. 

26.  Martius,  "  Ueber  Grosse,  Lage,  und  Beweglichkeit  des  gesunden  und 
kranken  Magens,"  Verhandlungen  der  66.  Naturforscherversammlung,  1894. 

27.  Meinert,  E.,  "  Ueber  einen  bei  gewohnlicher  Chlorose  des  Entwickel- 
ungsalters  anscheinend  konstanten  Befund,"  etc.,  Volkmann^ s  Smnmlung  klin. 
Vortrage,  1895,  Nr.  115  u.  116. 

28.  Meinert,  E.,  "  Zur  diagnostischen  Yerwerthbarkeit  der  Magendurch- 
leuchtung,"  Cejttralbl.f.  klin.  Med.,  1895. 

29.  Meinert,  E.,  "Ueber  normale  und  pathologische  Lage  des  menschlichen 
Magens  und  ihren  Xachweis,"  Centralbl.f.  innere  Med.,  1896. 

30.  Meltzing,  "  Magendurchleuchtungen,"  Zeitschr.f.  klin.  Med.,  xxvii. 

31.  Meltzing,  "  Gastroptose  und  Chlorose,"  Wiener  med.  Presse,  1895. 

32.  Munk  und  Uffelmann,  "Die  Ernahrung  des  gesunden  und  kranken 
Menschen,"  2.  Aufl.,  Wien  und  Leipzig,  1891. 

33.  Miiller-Warneck,  "  Ueber  die  widernatiirliche  Beweglichkeit  der  rechten 
Niere,"  Berl.  klin.  Wochenschr.,  1877. 

34.  Moritz,  "  Studien  iiber  die  motorische  Thiitigkeit  des  Magens,"  Zeitschr. 
f.  Biologic,  XXXII,  Neue  Folge,  xiv. 

35.  Riegel,  "Die  Erkrankungen  des  ^lagens,"  Wien,  1896. 

36.  Runeberg,  "  Ueber  die  kiinstliche  Aufblahung  des  Magens  und  des 
Dickdarms  durch  Luft,"  Deutsches  Archiv  f.  klin.  Med.,  1884,  Bd.  xxxiv. 

37.  Volcker,   "  Die  Schadlichkeit  des  Schniirens."     Diss.     Miinchen,   1893. 

38.  Weil,  "  Handbuch  und  Atlas  der  topographischen  Percussion,"  Leipzig, 
1880. 


628  ENTEROPTOSIS GASTROPTOSIS. 

39.  Weil,  "  Die  Wanderleber  und  der  Hangebauch  der  Frauen,"  Berlin, 
1885  (extensive  literature). 

40.  Malbranc,  "  Ein  complicirter  Fall  von  Magenerweiterung,"  Berl.  klin. 
Wochenschr.,  1880,  No.  28. 

41.  Schultz,  E.,  "  Wanderniere  und  Magenerweiterung,"  Prager  med. 
Wochenschr.,  14.  Januar,  1885. 

42.  Oser,  "  Die  Ursachen  der  Magenerweiterung,"  Wiener  Klinik,  Januar, 
1881. 

43.  A'.  Fischer-Benzon,  "  Ein  Beitrag  zur  Anatomic  und  Aetiologie  der 
beweglichen  Niere."    Inaug.-Diss.     Kiel,  1887. 

44.  Weisker,  CI.,  "Ueber  den  sog.  intra-abdominellen  Druck,"  Schmidt's 
Jahrbiicher  der gesainjnten  Medizin,  Bd.  ccxix,  S.  227. 

45.  Lindner,  "  Ueber  die  Wanderniere  der  Frauen,"  Neuwied,  1888. 

46.  Fereol,  "  De  I'Enteroptose,"  Bulletin  de  la  Socictc  Med.  des  Hopitaux, 
5.  Janv.,  1887,  et  12.  Novembre,  1888. 

47.  Cuilleret,  "Etude  Clinique  sur  I'Enteroptose  ou  Maladie  de  Glenard," 
Gazette  des  Hopitaux,  22.  Sept.,  1888,  et  No.  105,  1889. 

48.  Cheron,  "  De  I'Enteroptose,"  Union  Med.,  20.  Dec,  1S88. 

49.  Pourcelot,  "  De  I'Enteroptose."     Paris,  1889. 

50.  Dujardin-Beaumetz,  "Xeurasthenie  Gastrique  et  leur  Traitement,  Lemons 
de  I'Hopital  Cochin,  in  the  Therapeut.  Gaz.,  15.  Jan.,  1890. 

51.  Trastour,  "  Les  Desequilibres  du  Ventre,  Enteroptosiques  et  Dilates," 
Setnaine  Medic,  7.  Sept.,  1887. 

52.  Krez,  L.,  "Zur  Frage  der  Enteroptose,"  Munchener  med.  Wochenschr., 
No.  35,  1892. 

53.  Hilbert,  "  Ueber  palpable  und  bewegliche  Xieren,"  Deutsches  Archiv  f. 
klin.  Med.,  1892,  Bd.  l.,  S.  483. 

54.  Chapotot,  Vgl.,  "  L'Estomac  et  le  Corset,"  Paris,  1891. 

55.  Fromont,  "Anatomie  de  la  Portion  Abdominale  de  I'lntestin  ,"  These  de 
Lille,  1890. 

56.  Einhorn,  M.,  "  Die  Gastrodiaphanie,"  Xeiv  Yorker  med.  IVochenschr., 
1889. 

57.  Reichmann  und  Heryng,  "Ueber  electrische  Magen- und  Darmdurch- 
leuchtung,"  Therap.  Mojiatshefte,  1892,  S.  12S. 

58.  Kumpf,  "  Ueber  die  Wanderniere  der  Frauen  und  deren  Behandlung," 
Wiener  med.  Blatter,  1890,  Nr.  14. 

59.  V.  Bachmaier,  "Die  Wanderniere  und  deren  manuelle  Behandlung 
nach  Thure  Brandt,"   Wiener  med.  Presse,  1892,  Nr.  19  u.  20. 

60.  Arendt,  "  Ueber  Mastcuren  und  ihre  Anwendung  bei  chronischen 
Krankheiten  der  weiblichen  Sexualorgane,"  Pherap.  Mo?tatshefte,  1892, 
Heft  I,  S.  9. 

61.  Keppler,  "  Die  Wanderniere  und  ihre  chirurgische  Behandlung,"  Berlin, 

1879. 

62.  Sulzer,  AL,  "  Ueber  Wanderniere  und  deren  Behandlung  durch  Neph- 
rorrhagie,"  Deutsche  Zeitschr.f.  Chirurgie,  1891,  Bd.  xxx,  S.  506.  (This  arti- 
cle contains  the  complete  literature  on  the  pathology  and  treatment  of  floating 
kidney  up  to  1890.) 


LITERATURE    ON    GASTROPTOSIS    AND    ENTEROPTOSIS.  629 

63.  Hahn,  "  Operative  Behandlung  der  beweglichen  Niere  durch  Fixation," 
Centralbl.  f.  Chirurgie,  1881,  No.  29.     (Nephrorrhaphy.) 

64.  Meinert,  E.,  "  Zur  Aetiologie  der  Chlorose,"  Wiesbaden,  1894. 

65.  Glenard,  "  De  I'Enteroptose,  conference  facite  a  I'hopital  de  Mustapha," 
Alger-Lyon,  Janv.,  1889.     Presse  med.  Belg.,  Bruxelles,  1889. 

66.  Knapp,  Ludwig,  "  Wanderniere  bei  Frauen,"  Monograph  (Report  from 
Rosthorn's  Clinic  in  Prag),  Berlin,  1896. 

67.  Stiller,  B.,  "  Enteroptose  im  Lichte  eines  neuen  Stigma  neurasthenicum," 
Archiv f.  Verdauu7igskrankh.,  Bd.  II,  S.  285. 

68.  Lusaka,  "  Lage  der  Bauchorgane,"  Atlas,  Karlsruhe,  1873. 

69.  Hasse,  "  Bewegung.  d.  Zwerchfells — Einfluss  derselben  auf  d.  Unter- 
leibsorgane,"  Archiv  f.  Anat.  und  Physiol.,  1886,  S.  185. 

70.  Hufschmidt,  "  Pathol,  und  Therap.  d.  Enteroptose,"   JVien.  klin.  Woch- 
enschr.,  1892,  Nr.  52,  including  Literature. 

71.  Pick,  A.,  "  Magen-  und  Darmkrankheit.,"  Wien,  1895,  pages  179  to  188 
(35  bibliographical  references). 


CHAPTER    IX. 

NEUROSES   OF    THE   STOMACH. 

Gastric  neuroses  may  be  classified  as  follows  : 
I.  Motor. 
II.  Sensory. 
III.  Secretory. 

Under  each  one  of  these  we  may  distinguish 
(a)  States  of  excitation. 
(d)   States  of  depression  of  nervous  influences. 

I.  Neuroses  of  Motility,  or  Peristalsis. 
{a)  Irritative  states  : 

(i)  Cramp  of  the  cardia,  or  cardiospasm. 

(2)  Cramp  of  the  pylorus,  or  pyloric  spasm. 

(3)  Cramp  of  the  entire  musculature,  or  gastrospasm. 

(4)  The  peristaltic  unrest  of  Kussmaul. 

(5)  Nervous  eructation. 

(6)  Nervous  vomiting. 
(^)   Depressive  states  : 

(i)  Insufficiency    of  the    cardia,   including   rumination    and 
regurgitation. 

(2)  Insufficiency  or  incontinence  of  the  pylorus. 

(3)  Atony  or  insufficiency  of  the  entire  gastric  musculature 

(gastroplegia). 
II.  Sensory  Neuroses. 

{a)  Irritative  states  : 
(i)  Hyperesthesia. 

(2)  Gastralgia. 

(3)  Bulimia  and  polyphagia. 
(d)  Depressive  states  : 

(i)  Acoria. 
(2)  Anorexia. 
III.  Neuroses  of  Secretion. 
{a)  Irritative  states  : 

(i)  Hyperchylia,  hyper-  or  superacidity. 
(2)  Supersecretion  or  gastrosuccorrhea,  gastroxynsis. 
(1^)  Depressive  states  : 

(i)  Hypochylia  or  subacidity. 
(2)  Achylia  gastrica  or  inacidity. 
Nervous  Dyspepsia. 

630 


GENERAL    CONSIDERATIONS.  63  I 

General  Considerations, — All  diseases  of  the  stomach  in  which 
no  pathological  anatomical  change  can  be  demonstrated  in  the 
organ  are  classed  as  neuroses.  Hitherto  we  have  considered  only 
diseases  that  were  based  upon  an  actual  alteration  in  the  structure 
of  the  stomach.  Neuroses,  then,  are  idiopathic  diseases  of  the 
gastric  nerves,  with  absence  of  histological  changes  that  can  be 
demonstrated  in  the  tissues.  The  gastric  nerves  can  be  affected,  it 
is  true,  in  the  course  of  gastritis,  ulcer,  carcinoma,  and  dilatation, 
by  the  changes  in  the  deeper  layers  of  the  stomach  brought 
about  by  these  diseases.  A  large  portion  of  the  dyspeptic  distur- 
bances, as  well  as  of  the  anomalies  of  secretion  and  motility,  are 
attributable  to  injurious  influences  exerted  upon  the  nerves  in  the 
course  of  these  diseases.  These  nervous  affections  which  accom- 
pany changes  in  the  gastric  structure  are  known  as  secondary 
symptomatic  nervous  disturbances.  It  is  very  probable  that  ana- 
tomical changes  may  lie  at  the  foundation  of  many  neuroses,  but  up 
to  the  present  time  they  escape  our  microscopic  technic.  For  in- 
stance, in  more  than  half  the  cases  of  hyperacidity  a  proliferation 
of  the  oxyntic  cells,  or  of  the  glands  as  a  whole,  has  been  ascer- 
tained by  Hayem,  Einhorn,  Cohnheim,  and  the  author.  It  is  more 
than  probable,  also,  that  atrophy  is  present  in  from  one-half  to  two- 
thirds  of  the  cases  of  achylia  gastrica.  With  further  progress  and 
improvement  of  our  methods  of  staining  and  hardening  the  num- 
ber of  gastric  neuroses  will  become  more  and  more  reduced. 

The  histological  changes  in  the  mucosa  accompanying  h}-per- 
chylia  and  achylia  are  not  caused  by  the  nervous  condition,  but 
constitute  a  primary  affection  independent  of  the  neurosis.  This  is 
made  probable  by  the  fact  that  proliferation  of  oxyntic  cells  and 
of  gland  tubules, can  be  found  at  the  autopsy,  in  the  stomachs  of 
individuals  who  have  never  shown  any  symptoms  of  ner\-ous  dis- 
eases or  neurasthenia,  and  also  because  proliferation  has  been  found 
in  fragments  of  mucosa  gained  from  the  wash-water  of  perfectly 
normal  individuals  so  far  as  any  neuropathic  state  was  concerned. 

When  the  gastric  nervous  apparatus  is  the  primary  seat  of  the 
disease,  it  is  called  a  primary  neurosis,  but  when  the  disease  of  the 
gastric  nerves  is  reflexly  excited  from  the  central  nervous  system, 
or  from  other  organs,  such  as  the  intestines,  liver,  spleen,  and  kid- 
neys, it  is  called  a  secondary  or  reflex  neurosis.  Neuroses  may 
cause  secondary  anatomical  alterations  in  the  stomach  ;  for  instance, 
if  anacidity  is  associated  with  impaired  niotilit}-.  we  ma}-  have  a  gas- 


632  NEUROSES    OF    THE    STOMACH. 

tritis  develop  from  decomposition  of  a  stagnating  ingesta.  When 
hyperacidity,  or  supersecretion,  causes  a  persistent  spasm  of  the  py- 
lorus, a  dilatation  may  result  producing  the  same  symptoms.  Dis- 
turbances of  the  sensory  nerves  of  the  stomach  may  extend  to  the 
bowels  and  bring  about  the  so-called  neurasthenia  or  nervous  dys- 
pepsia of  the  intestines  ;  with  persistent  nervous  atony  of  the 
stomach,  the  motility  of  the  intestine  frequently  begins  to  suffer 
also.  This,  apparently,  is  a  direct  extension  of  the  nervous  trouble 
to  the  intestines.  In  achylia  gastrica,  when  the  antiseptic  effect  of 
the  HCl  is  missing,  an  excessive  putrefaction  of  the  intestinal  con- 
tents with  abundant  formation  of  gases  is  sometimes  noticed,  so 
that  the  intestinal  wall  becomes  very  much  expanded,  and  an 
atony  can  arise  in  this  manner.  It  is  well  known  that  strong 
psychic  impressions  and  emotions  like  anger,  aggravation,  fright, 
fear,  and  sadness,  as  well  as  excessive  joy,  can  completely  sup- 
press the  appetite.  In  ver}^  excitable  people  these  emotions  may 
even  cause  eructation,  nausea,  and  severe  gastralgia.  These 
nervous  disturbances  mend  rapidly,  as  a  rule,  when  the  mind  has 
been  quieted,  but  when  the  emotional  excitement  was  great,  and 
frequently  repeated  within  a  short  time,  particularly  in  very  excita- 
ble, neuropathic  individuals,  a  lasting  neurosis  may  develop. 

Gastric  neuroses  which  are  the  result  of  functional  or  anatomical 
diseases  of  the  nervous  central  organs,  or  of  hysteria  and  neuras- 
thenia, may  be  so  masked  that  the  fundamental  disease  may  be 
completely  submerged,  and  be  little  regarded  by  the  patient,  and 
is  not  discovered  by  the  physician  until  after  a  careful  study  of  the 
case  has  been  made.  In  sclerosis  of  the  posterior  columns  of  the 
spinal  cord  (tabes  dorsalis)  a  train  of  gastric  symptoms  has  been 
first  described  by  Charcot  under  the  name  of  "  crises  gastriques." 
They  are  described  as  intense  cramp-like  pains  occurring  suddenly 
in  the  midst  of  comparative  well  being,  and  radiating  toward  the 
abdomen  and  back  ;  they  are  usually  followed  by  copious  vomiting. 
The  vomit  at  first  consists  of  food,  and  later  of  mucus,  bile,  and 
duodenal  secretions,  and  may  occur  several  times  in  the  same  day, 
frequently  every  hour.  These  attacks  appear  and  disappear  very 
rapidly,  and  are  separated  by  long  intervals  of  perfect  freedom  from 
gastric  disturbances.  Ewald  emphasizes  that  these  attacks  may 
occur  in  tabes  so  early  in  the  disease  that  the  fundamental  affection 
can  not  at  all  be  diagnosed  because  all  typical  symptoms  are  wanting. 
Sensations  of  a  borino-  and  burning  character  and  severe  gastralgia 


REFLEX    NEUROSES    OF    THE    STOMACH.  633 

may  be  present  in  tabic  patients  years  before  the  spinal  disease  is 
recognizable.  In  other  anatomical  diseases  of  the  nervous  central 
organs,  in  myelitis  due  to  compression,  meningitis,  brain  tumors, 
and  after  powerful  concussions  of  the  brain  and  spinal  cord,  nerv- 
ous gastric  disturbances  appear.  In  the  progress  of  certain  dis- 
eases of  the  medulla,  repeated  nausea  and  vomiting  may  be  attributed 
to  irritation  of  the  vomiting  center.  Reflex  neuroses  of  the  stom- 
ach may  occur  from  disease  of  the  neighboring  organs,  as,  for 
instance,  from  the  liver,  intestines,  bile  passages,  spleen,  and  periton- 
eum, as  well  as  from  the  kidneys,  sexual  organs,  and  heart.  In 
biliary  colic  gastric  symptoms  are  rarely  absent.  We  generally 
find  that  gastralgia,  nausea,  vomiting,  eructation,  and  anorexia  are 
present  during  the  passage  of  gall-stones,  and  rapidly  disappear  as 
soon  as  the  stone  has  passed  through  into  the  intestine.  The  gastric 
complications  of  cholemia  and  cholelithiasis  do  not  disappear  so 
rapidly,  because  the  excretion  of  the  foreign  materials  in  the  blood 
of  cholemia,  and  the  correction  of  anatomical  changes  in  choleli- 
thiasis require  some  time.  Renal  colic  in  a  similar  manner  may 
cause  dyspeptic  symptoms.  Cases  are  reported  in  which  the  renal 
symptoms  were  so  masked  by  the  gastric  that  the  diagnosis  of 
ulcer  was  made.  This  may  very  readily  occur  when  the  nephritic 
pains  radiate  toward  the  back  and  shoulders  like  those  of  ulcers. 
Gastric  symptoms  occurring  as  a  sequence  to  uremia  are  the  result 
of  a  direct  or  indirect  irritation  of  the  central  nervous  organs,  and 
also  of  the  gastric  nerves  by  retained  products  of  catabolism.  In 
a  case  of  contracted  kidney  with  chronic  uremia  in  our  recent  prac- 
tice, the  patient  suffered  exclusively  from  gastric  symptoms,  but  test- 
meals  showed  that  the  motor  and  secretory  functions  were  normal, 
and  that,  therefore,  the  dyspeptic  complaints  were  disturbances  of 
the  sensory  nerves  of  the  stomach.  Diseases  of  the  sexual  organs, 
in  both  sexes,  but  particularly  in  women,  may  bring  about  reflex 
gastric  neurosis.  Kretschy  and  Fleischer  have  found  that  the 
physiological  process  of  menstruation  may  cause  disturbances  of 
function  in  the  stomach,  which  naturally  are  also  met  with  in  a 
more  exaggerated  form  in  dysmenorrhea,  in  the  diseases  of  the 
uterus  and  ovaries,  and  during  pregnancy.  Whatever  may  be  the 
etiological  culmination  of  factors  in  vomiting  of  pregnancy,  there  is 
no  better  explanation  offered  up  to  the  present  time  than  that  it  is  a 
reflex    neurosis   of  the  stomach  induced  by  the  expansion  of  the 


634  NEUROSES    OF    THE    STOMACH. 

■Uterus  and  irritation  of  the  sympathetic  fibers  caused  thereby.  R. 
Frommel  (Penzoldt  and  Stintzing's,  "  Handbuch  d.  specielle  Therap. 
innerer  Krankheiten,"  Bd.  iv,  p.  440)  has  obtained  very  good  results 
in  this  disease  with  basic  orexin,  a  medicine  which  acts  mainly  in 
nervous  affections,  and  rarely  in  anatomical  alterations  of  the 
stomach. 

Gastric  neuroses  are  much  more  frequently  seen  in  women  than 
in  men.  Women  and  girls  of  the  better  classes  constitute  the  pre- 
vailing number  of  those  affected  with  gastric  neuroses.  The  recog- 
nition of  pure  gastric  neuroses  and  whether  they  exist  as  idio- 
pathic independent  diseases,  or  are  in  some  causal  relation  to  a 
pre-existing  disease,  like  those  we  have  mentioned,  is  often  a 
problem  presenting  great  difficulties.  The  stomach  is  an  organ 
that  is  very  rich  in  nerves,  and  is  inclosed  in  a  widely  connected 
network  of  fibers  which  bring  it  into  close  connection  with  other 
vital  organs.  Concerning  the  anatomy  and  physiology  of  the  gas- 
tric nerves,  we  may  say  that  the  innervation  of  the  organ  is  carried 
out  above  all  by  the  vagi.  The  left  vagus  spreads  over  the  cardiac 
portion  and  the  lesser  curvature,  and  forms  the  anterior  gastric 
plexus  with  fibers  coming  from  the  abdominal  sympathetic.  The 
right  vagus  supplies  mainh'the  liver,  pancreas,  spleen,  kidney,  and 
small  intestine,  and  a  small  part  of  its  branches  reaches  the  pos- 
terior wall  of  the  stomach.  Anastomoses  from  the  abdominal 
sympathetic  with  branches  of  the  right  vagus  form  the  posterior 
gastric  plexus.  The  vagi  also  enter  into  the  formation  of  the  celiac 
or  solar  plexus.  Branches  from  the  solar  plexus  form  the  so-called 
superior  coronary  plexus  of  the  stomach  lying  along  the  lesser 
curvature,  while  branches  coming  from  the  hepatic  plexus  and  run- 
ning along  with  the  right  inferior  coronary  artery  form  the  inferior 
coronary  plexus  of  the  stomach.  These  four  plexuses  are  united 
into  a  great  network  b}'  connecting  communicative  branches.  In 
the  p3'loric  portion,  the  beginnings  of  the  large  and  important  intes- 
tinal plexuses  can  be  demonstrated.  The  intestinal  sympathetic 
nerves  form  a  network  with  close  meshes  in  the  submucosa  as  well 
as  in  the  muscular  layer.  In  the  broadened  points  of  union  of  this 
nervous,  network  are  found  numerous  ganglion  cells.  The  Meiss- 
ner  network  supplies  the  muscularis  mucosae,  and  the  mucosa  and 
the  intermuscular  plexus  of  Auerbach  supply  the  muscular  layers 
with  very  fine  branches.     Openchowsky  has  demonstrated    large 


THE    COURSE    OF    GASTRIC    NEUROSES.  635 

masses  of  ganglion  cells  not  only  at  the  pylorus,  but  all  along  the 
fundus  and  cardia  in  the  serosa;  these  ganglia  are  in  communi- 
cation with  the  large  vagosympathetic  fibers. 

What  we  know  of  the  physiology  of  the  gastric  nerves  is,  up  to 
the  present  time,  very  limited.  Experimental  physiology  has  as 
yet  not  cleared  up  gastric  innervation.  It  is  not  even  known 
whether  secretion  is  influenced  by  the  vagus  nerves,  nor  by  what 
nerve  routes  the  sensation  of  hunger  is  transmitted.  The  influence 
of  the  vagus  and  sympathetic  fibers  on  peristalsis  is  also  quite 
unknown.  Although  we  do  not  know  the  paths  of  vast  secretory 
motor  and  absorptive  impulses,  nor  of  sensation,  it  is  generally 
assumed  on  clinical  grounds  that  each  of  these  functions  is  repre- 
sented by  different  nerves,-  and  we  therefore  accept  the  existence 
of  special  nerves  for  motion,  sensation,  secretion,  and  absorption. 
Clinical  experience  has  confirmed  this  assumption  because  peri- 
staltic, sensory,  and  secretive  disturbances  may  exist  by  themselves. 

All  gastric  neuroses  may  show  considerable  variation  in  their 
course.  Thus  the  contents  of  the  stomach  may  one  day  show 
inacidity  or  achylia,  and  on  the  next  day  show  hyperchylia.  In 
the  same  manner  we  may  find  motor  insufficiency  alternating  with 
peristaltic  unrest.  Although  the  neuroses  may  exist  singly  as  in- 
dividual diseases,  we  are  confronted,  as  a  rule,  with  combinations 
of  various  disturbances.  Thus  we  may  find  that  hyperacidity  and 
gastrospasm  are  associated  with  each  other,  that  hyperesthesia  will 
be  combined  with  vomiting,  and  that  superacidity  will  be  present 
in  atony.  These  diseases  may  develop  pronounced  attacks  at 
periods  when  the  stomach  is  resting.  The  intensity  of  the  attack 
is  very  frequently  entirely  independent  of  the  quantity  or  quality 
of  the  food,  but  the  effect  of  psychic  influences  is  generally  unmis- 
takable. Neuroses  may  exist  side  by  side  with  organic  diseases  of 
the  stomach,  but  as  a  rule  they  are  part  of  the  symptomatology  of 
neurasthenia  or  hysteria.  The  symptoms  of  a  general  neurosis 
are  rarely  absent ;  that  is,  the  characteristic  changes  of  the  psychic 
disposition,  the  lassitude,  irritability,  feeble  memory,  indisposition 
to  work,  insomnia,  neuralgia,  migraine,  vertigo,  polyuria,  weakness 
of  the  bladder,  and  a  varying  pain.  All  these  neuroses  which  we 
have  mentioned  are  really  not  individual  diseases,  but  rather  symp- 
toms ;  but,  as  these  symptoms  generally  occur  with  a  certain  inde- 
pendence and  are  disturbances  peculiar  to  themselves,  it  will  not  be 
unlogical  to  call    the    complex    anomalies    by    the    name  of  one 


636  NEUROSES    OF    THE    STOMACH. 

symptom,  so  that  we  will  speak  of  cardiac  spasm  and  nervous 
eructation  and  hyperacidity  as  diseases  peculiar  to  themselves 
(neuroses  sui generis),  bearing  in  mind,  however,  that  we  are  simply 
describing  symptoms. 

CARDIOSPASM   (Cramp  of  the  Cardia). 

The  etiology  of  spasm  of  the  ring  musculature  of  the  cardia 
agrees  fully  with  that  of  cramp  of  the  pylorus.  In  the  great 
majority  of  cases  the  cramp  of  the  cardia  represents  a  secondary 
disease,  which  may  appear  with  hyperesthesia  and  very  strong  irri- 
tation of  the  mucous  membrane  of  the  cardiac  region  ;  further,  with 
abnormal  dilatation  of  the  stomach  through  air  and  gases,  as  well 
as  with  caustic  action  upon  the  mucous  membrane  present  with  ulcer 
and  ulcerating  carcinoma  of  the  cardia  ;  hence,  it  is  produced  by 
the  same  causes  as  cramp  of  the  pylorus.  Much  more  rarely  the 
spasm  of  the  cardia  is  due  to  a  genuine  symptomatic  or  idiopathic 
neurosis  of  the  motor  apparatus,  which  is  characterized  by  an  in- 
creased irritability.  It  is  observed  as  a  partial  symptom  of  hysteria 
and  neurasthenia,  simultaneous  with  other  nervous  disturbances, 
which  may  facilitate  the  recognition  of  the  neuropathic  basis  of  this 
form  of  cramp.  Whether  cramp  of  the  cardia  as  a  pure  neurosis 
of  the  motor  apparatus  is  a  functional  impairment  of  the  peri- 
pheral motor  nerve  apparatus,  or  whether  it  is  of  central  origin, 
is  at  present  still  a  debated  question.  We  may  distinguish  two 
forms  of  cramp  of  the  cardia  : 

(i)  Acute  cramp,  which,  appearing  rather  suddenly,  often  spas- 
modically, is  generally  only  of  short  duration. 

(2)  Chronic  cramp,  which  is  a  very  stubborn  and  serious  disease. 

One  of  the  most  frequent  causes  of  the  rare  form  of  secondary 
cramp,  is  dilatation  of  the  stomach  by  air  and  gases.  An  abnormal 
dilatation  of  the  stomach  by  air,  which  may  finally  bring  about  a 
cramp  of  the  cardia,  is  only  found  in  those  persons  who  have  the 
nervous  habit  of  swallowing  large  quantities  of  air.  If  the  air 
is  not  soon  removed  through  eructation,  it  keeps  on  collecting  in 
the  stomach  and  expands  on  becoming  warmed,  so  that  finally  a 
considerable  dilatation  of  the  stomach  is  produced,  and  with  it 
cramp  of  the  cardia,  which  is,  perhaps,  always  complicated  with 
cramp  of  the  pylorus.  Ewald  and  Fleischer  have  had  oppor- 
tunity to  examine  repeatedly  cases  of  intentional  swallowing  of  air. 
Fleischer's  case  was  a  girl  who  had  been  practising  it  as  a  kind  of 


DILATATION    OF    THE    STOMACH.  637 

sport  for  many  years.  The  stomach  was  constantly  dilated,  even  in 
a  jejune  state,  and  felt  like  an  air-pillow.  The  rounding  of  the 
region  of  the  stomach  was  plainly  visible,  even  through  the  cloth- 
ing. The  elastic  stomach-tube  introduced  into  the  esophagus  met 
an  obstruction  at  the  cardia,  which  was  not  easily  overcome,  even 
after  the  insertion  of  the  tube  into  the  stomach.  When  the  outer 
end  was  put  into  water,  numerous  bubbles  of  air  escaped  through 
it ;  but  even  with  a  strong  external  pressure  in  the  region  of  the 
stomach  one  could  not  succeed  in  removing  all  the  air.  The  resist- 
ance in  this  region  continued,  though  to  a  less  degree.  With 
repeated  thorough  palpation,  it  was  discovered  that  the  cramp  of 
the  cardia  and  pylorus,  occurring  intermittently  for  many  years, 
had  caused  a  hypertrophy  of  the  musculature  of  the  stomach  ;  and 
it  was  this  condition,  probably,  which  prevented  the  formation  of  a 
more  severe  atony  and  ectasia  of  the  stomach,  for  the  lower  limit 
of  the  stomach  was  only  slightly  below  the  normal. 

The  stomach  may  also  be  dilated  by  a  very  copious  intragastric 
formation  of  gases  to  such  a  degree  that  a  cramp  of  the  cardia 
arises;  and  this  happens  very  easily  when  the  formation  of  gases 
is  very  rapid,  as  is  observed  sometimes  with  protracted  stagnation 
of  the  ingesta  in  the  stomach,  as  a  result  of  atony,  ectasia,  chronic 
gastritis,  advanced  stenosis  of  the  pylorus  or  duodenum,  as  well 
as  with  primary  and  secondary  cramp  of  the  pylorus,  when  the 
contents  of  the  stomach  are  subject  to  fermentation  and  decom- 
position. If  the  gases  can  not  pass  over  into  the  intestine,  they  con- 
tinue to  collect  in  the  stomach,  so  that  it  finally  becomes  very  much 
dilated.  The  region  of  the  stomach  becomes  arched,  and  trouble- 
some sensations  of  pressure  and  tension  appear  in  the  same.  If 
the  stomach  presses  the  diaphragm  upward,  and  if  the  latter  in 
turn  presses  on  the  lower  part  of  the  lung  and  the  heart,  dyspnea, 
precordial  oppression,  palpitation  of  the  heart,  and  asthma  dyspep- 
ticum  may  result.  With  this  there  sometimes  exists  great  pros- 
tration, rapid,  soft  pulse,  and  headache.  That  these  very  often 
dangerous  symptoms  are  really  caused  by  the  dilatation  of  the 
stomach  and  not,  perhaps,  by  auto-intoxication — that  is,  by  pro- 
ducts of  fermentation  and  putrefaction  of  the  chyme — is  evident 
from  the  fact  that  the  symptoms  cease  quickly  when  the  cardial 
closure  is  finally  broken  (the  pylorus,  on  account  of  its  very 
much  stronger  ring  musculature,  offers  a  much  greater  resistance 
to  the  passage  of  the  gases  into  the  intestines),  when  the  spasm 
42 


638  NEUROSES    OF    THE    STOMACH. 

relaxes,  or  a  tube  is  introduced   into  the   stomach,  and  the  air  or 
gases  have  an  opportunity  to  escape  outwardly. 

On  the  other  hand,  the  cramp  of  the  cardia  may  also  be  primary, 
and  the  dilatation  of  the  stomach  (pneumatosis)  may  be  secondary. 
If  the  cramp  of  the  cardia  sets  in  immediately  after  the  meal,  and  if 
the  eructation  of  the  air  which  is  swallowed  during  the  meal  with 
the  food  and  liquids  is  prevented,  then  the  stomach  may  also 
become  abnormally  distended.  Since  the  neuromuscular  apparatus 
of  the  cardia  is  mechanically  irritated  with  strong  distention 
of  the  stomach,  the  cramp  is  thereby  continued,  and,  therefore, 
the  cramp  probably  lasts  longer  during  digestion  than  with 
an  empty  stomach.  Just  as  the  removal  of  air  and  gases  from 
the  stomach  through  eructation  is  sometimes  made  entirely  im- 
possible by  a  primary  or  secondary  cramp  of  the  cardia,  so 
the  removal  of  the  contents  of  the  stomach  by  vomiting  may 
also  be  made  impossible.  Even  the  strongest  efforts  at  vomiting 
bring  up  nothing,  and  patients  maybe  much  tormented  by  fruitless 
muscular  exertion.  When  this  is  of  long  duration  and  frequent 
repetition  it  may  bring  about  atony  of  the  stomach  in  consequence 
of  overexertion  of  the  musculature.  If  the  cramp  is  caused  as  a 
secondary  or  reflex  neurosis  by  hyperesthesia,  strong  irritation,  or 
ulceration  of  the  mucous  membrane  of  the  cardia,  it  sometimes 
produces  a  painful  feeling  of  contraction  in  the  region  of  the  cardia, 
which  may  radiate  toward  the  breast,  the  back,  and  to  the  region 
of  the  heart.  It  has  been  asserted  that  the  cramp  which  appears 
as  a  pure  neurosis  of  the  motor  apparatus  may  also  cause  the  same 
sensations  of  pain,  but  this  is  not  very  probable.  At  least  the 
observations  with  that  form  of  cramp  of  the  pylorus  which  is  not 
dependent  upon  the  states  of  disease  before  mentioned,  but  de- 
pends simply  upon  a  pure  neurosis  of  the  motor  apparatus,  argue 
against  it,  since  the  latter  is  not  accompanied  by  pain.  The  pains 
described  are  not  a  constant  symptom,  and,  therefore,  may  not  be 
used  as  a  factor  in  a  differential  diagnosis  of  the  two  forms  of  cramp. 
Since  with  an  entirely  empty  stomach  the  acute  spasm  produces 
no  symptoms,  it  may  for  some  time  remain  latent,  and  is  sometimes 
recognized  only  by  accident  when  from  some  cause  a  tube  is  intro- 
duced into  the  stomach  which  meets  an  obstruction  in  the  region 
of  the  cardia,  or  when  food  or  drink  is  taken  by  the  patient 
during  the  cramp,  deglutition  being  then  somewhat  hindered. 
Chronic    cardiospasm   gives    much    more    significant    symptoms. 


DIAGNOSIS    OF    CARDIOSPASM.  639 

Besides  the  symptoms  mentioned  previously,  very  severe  complaints 
from  deglutition  appear.  The  patients  have  the  unmistakable 
feeling  that  some  of  the  food  becomes  stuck  before  it  reaches  the 
stomach.  If,  in  spite  of  this,  the  meal  is  continued,  the  lower  part 
of  the  esophagus  is  filled  with  food,  and  after  some  time  the 
patients,  with  great  exertions,  sometimes  succeed  in  bringing  it 
up  again  in  almost  an  unchanged  condition.  That  it  comes  from 
the  esophagus  and  not  from  the  stomach,  is  shown  by  the  absence 
of  the  free  hydrochloric  acid  in  the  same.  The  second  deglutition 
sound  (auscultation  over  the  lower  part  of  the  sternum)  is 
always  lacking,  and  in  its  place  a  low  rippling  noise  may  be  heard, 
which  probably  arises  from  the  circumstance  that  the  cardia  is  not 
completely  closed,  and  liquids  pressed  on  may  still  flow  into  the 
stomach.  With  protracted  duration  of  the  malady,  the  ingesta  re- 
maining in  the  lower  part  of  the  esophagus  may  exert  such  a  pres- 
sure upon  its  walls  that  a  diverticulum  may  be  formed  which  pre- 
vents the  taking  in  of  food.  The  nutrition  of  patients  may  be  much 
reduced,  so  that,  especially  when  the  patients  are  advanced  in  age, 
the  suspicion  may  arise  that  a  carcinoma  of  the  cardia  is  developing, 
which,  as  we  know,  can  also  cause  a  stenosis  of  the  cardia  as  well 
as  the  formation  of  a  diverticulum. 

Fortunately,  chronic  cramp  of  the  cardia  is  a  very  rare  malady ; 
it  may  exist  for  months,  even  years. 

Prognosis. — The  prognosis  of  the  acute  primary  or  secondary 
cramp  of  the  cardia  is,  on  the  whole,  favorable,  especially  when  it  is 
recognized  in  time,  and  if  one  is  successful  in  rapidly  removing  its 
fundamental  causes, — swallowing  of  air,  formation  of  gases  in  the 
stomach,  hyperacidity,  hypersecretion,  atony,  hyperesthesia,  etc. 
On  the  other  hand,  its  prognosis  is  always  to  be  made  with  caution, 
especially  when  there  has  already  been  formed  a  diverticulum  of  the 
esophagus  which  hinders  the  passage  of  food. 

Diagnosis. — In  order  to  distinguish  acute  primary  and  second- 
ary cramp,  one  must  learn,  above  all,  if  one  of  the  states  of  disease 
before  mentioned  which  can  produce  cramp  of  the  cardia,  can  be 
detected.  With  repeated  thorough  investigations  one  generally 
succeeds  in  determining  the  cause  of  the  secondary  cramp.  If 
it  is  due  to  hyperesthesia,  to  a  strong  irritation,  or  to  loss  of 
substance  of  the  mucous  membrane  of  the  cardia,  then  pains  in 
the  region  of  the  cardia  often  draw  attention  to  this  manner  of 
orig-in.  and  the  introduction  of  a  tube  into  the  stomach  will  then 


640  NEUROSES    OF    THE    STOMACH. 

cause  pain  also.  But  if  a  decided  cause  for  the  cramp  can  not  be 
discovered,  if  it  recurs  periodically,  if  it  is  always  of  rather  short 
duration,  and  if  other  nervous  troubles  are  present,  then  probably 
there  exists  a  symptomatic  functional  neurosis  ;  and  if  all  these 
signs  are  lacking,  then  there  is  an  idiopathic  functional  motor  neu- 
rosis, but  this  is  a  very  rare  occurrence. 

The  diagnosis  of  the  chronic  cardiospasm  leading  to  a  perma- 
nent closure  of  the  cardia  is  more  difficult,  because  it  may  easily 
be  mistaken  for  carcinoma  or  malignant  stenosis  of  the  cardia,  as 
well  as  for  a  diverticulum  of  the  lowest  part  of  the  esophagus, 
which,  however,  is  rare. 

Advanced  age,  anemia,  and  cachexia,  appearing  at  a  time  in 
which  the  passage  of  food  is  not  yet  hindered  to  a  great  ex- 
tent, argue  for  carcinoma  of  the  cardia.  In  the  food  brought  up 
by  regurgitation,  as  well  as  in  the  examination  with  the  tube,  one 
often  finds  traces  of  blood,  and  in  some  few  cases  particles  of  car- 
cinomatous structure  (in  the  aperture  of  the  tube).  In  most  of 
the  patients,  free  hydrochloric  acid  is  wanting  in  the  contents  or 
food  that  may  be  drawn  from  the  esophageal  diverticulum.  The 
more  the  stenosis  increases  with  the  progress  of  the  carcinoma, 
the  thinner  the  tubes  that  must  be  used,  in  order  to  pass. 
Cicatricial  stenosis  of  the  cardia  is  less  frequent,  a  diverticulum  of 
the  lowest  section  of  the  esophagus  much  rarer,  than  carcinoma  of 
the  cardia.  Both  diseases  are  not  connected  with  any  particular 
age.  The  nutrition  of  the  patients  is  decreased  only  when  the  pas- 
sage of  the  food  is  very  much  impeded.  In  the  formation  of  diver- 
ticulum traces  of  blood  in  the  contents  of  the  tube  are  generally 
lacking,  and  with  stenosis  they  are  very  rare.  With  diverticulum, 
tubes  of  different  thicknesses  sometimes  penetrate  into  the  stomach 
at  the  first  attempt,  at  other  times  only  after  many  fruitless 
endeavors,  according  as  the  stomach  is  full  or  empty.  With 
stenosis,  when  there  is  much  difficulty  in  deglutition,  only  thin 
tubes  can  penetrate.  In  both  maladies  there  are  no  anomalies  of 
secretion  in  the  stomach.  With  carcinoma,  as  well  as  with  stenosis 
of  the  cardia  and  with  diverticulum,  the  difficulties  of  deglutition 
increase  very  gradually,  while  in  the  case  of  cramp  they  generally 
come  to  an  acute  stage  in  a  short  time.  The  chronic  cramp,  which 
is  very  rare,  may  appear  at  any  age.  The  general  nutrition  suffers 
only  after  protracted  duration.      Traces  of  blood  can  neither  be 


THERAPEUTICS    OF    CARDIOSPASM.  64I 

found  in  the  examination  with  the  tube  nor  in  the  food  that  is 
eructated. 

The  examination  of  the  contents  of  the  stomach  in  cases  of  sim- 
ple cramp  of  the  cardia  shows  nothing  abnormal.  With  intermit- 
tent relaxation  of  the  cramp,  the  complaints  of  deglutition  cease  tem- 
porarily, and  a  rigid  tube  may  be  pushed  into  the  stomach  without 
meeting  with  any  resistance ;  neither  of  these  phenomena  are  ob- 
served with  carcinoma  and  stenosis,  except  in  the  rare  case  of  disinte- 
gration of  the  carcinoma.  An  important  distinction  of  the  cramp 
consists  in  the  fact  that  thick,  rigid  tubes  overcome  the  obstacle  at 
the  entrance  of  the  stomach  much  more  easily  than  thin  tubes  (Boas). 
Fleischer  has  made  the  same  observations  repeatedly  with  spastic 
stricture  of  the  urethra,  which  is  generally  a  result  of  hyperes- 
thesia of  the.  mucous  membrane  of  the  urethra.  If  in  this  case 
a  thin  catheter  is  introduced,  its  point,  with  moderate  pressure, 
irritates  only  one  spot  of  the  mucous  membrane,  and  by  this  a 
cramp  of  the  musculature  is  produced  (or  a  previously  existing 
one  is  increased),  which  is  so  severe  that  it  may  easily  be  mis- 
taken for  an  organic  stricture.  A  wrong  diagnosis  is,  however, 
easily  avoided  if  the  mucous  membrane  is  first  anesthetized 
with  a  five  per  cent,  cocain  solution.  Then,  after  a  short  time, 
one  can  push  the  catheter  further.  If  a  much  thicker  catheter  is 
introduced,  the  broader  point  of  the  same  will  exert  an  even  pres- 
sure upon  the  whole  mucous  membrane  at  the  point  in  question, 
which  is  not  so  irritating.  Probably  the  sensory  nerves  are  then 
for  a  time  paralyzed,  and  the  cramp  abates.  Very  likely  the  same 
conditions  obtain  in  the  probing  of  the  esophagus.  If  after 
protracted  duration  of  a  cramp  a  diverticulum  of  the  esophagus 
has  been  formed,  considerable  quantities  of  food  may  be  retched 
up  at  one  time,  and  a  thick  tube  will  then  pass  the  obstacle  at  the 
entrance  of  the  stomach,  the  facility  of  the  passage  depending  on 
the  fullness  of  the  diverticulum,  and  sometimes  the  passage  is  ac- 
complished only  after  many  unsuccessful  endeavors. 

Therapeutics. — The  patient  must  abstain  from  all  injurious 
influences.  The  abnormal  conditions  which,  according  to  experi- 
ence, produce  cramp  of  the  cardia,  must  be  removed.  Those  who 
swallow  air  must  be  cautioned  against  the  bad  effects  of  the  habit. 
With  strong  dilatation  of  the  stomach  through  air  and  gases, 
in  consequence  of  fermentation  and  stagnation  of  the  contents, 
the  air  and  gases  should  be   removed  as   quickly  as  possible  by 


642  NEUROSES    OF    THE    STOMACH. 

the  introduction  of  a  rather  thick,  rigid  tube,  and  a  more  copi- 
ous formation  of  gases  must  be  prevented  by  methodical  lavage  of 
the  stomach,  often  with  the  addition  of  antiseptics.  The  diet  must, 
for  some  time,  consist  of  milk,  and  later  of  various  meats  taken  in 
a  minced  form.  Other  nervous  disorders  must  receive  suitable 
treatment.  One  of  the  best  methods  of  treatment  for  cramp  of  the 
cardia  is  the  introduction  of  firm,  thick  tubes,  which  are  permitted 
to  remain  in  position  for  some  time.  Sometimes  the  cramp  ceases 
entirely  after  sounding  one  or  more  times.  If  the  spasm  is  the  con- 
sequence of  hyperesthesia  of  the  mucous  membrane  of  the  esoph- 
agus and  cardia,  the  sensibility  is  blunted  by  frequent  soundings. 

In  very  stubborn  cases  of  hyperesthesia  with  cardiospasm  it  is  ad- 
visable to  apply  a  solution  of  cocain  hydrochlorate  to  the  mucous 
membrane  just  before  the  meal,  in  order  to  prevent  the  appearance  of 
the  cramp.  For  this  purpose  one  had  best  use  a  small  sponge,  satu- 
rated with  a  three  per  cent,  solution  of  cocain,  and  fastened  to  the 
lower  end  of  an  open,  rather  thick,  firm  tube,  with  rounded  edges,  by 
means  of  a  strong  silk  thread  brought  through  the  tube  to  its  upper 
end.  After  introducing  the  tube  into  the  cardia,  the  cocain  solution 
is  forced  out  of  the  sponge  by  pulling  the  silk  thread,  or  by  blow- 
ing air  into  the  tube,  and  the  mucous  membrane  may  thus  be  anes- 
thetized. Another  way  of  accomplishing  this  is  with  the  Einhorn 
intragastric  spray,  by  which  the  lower  part  of  the  esophagus  and 
the  cardia  maybe  sprayed  with  cocain  and  menthol.  With  chronic 
cardiospasm  also,  the  methodical  introduction  of  firm  tubes  is  the 
most  successful  remedy.  The  effect  may  be  aided  by  external  or 
internal  gah^anization  (the  anode  in  the  tube).  According  to  an  in- 
teresting observation  of  Boas,  solid  foods  are  sometimes  introduced 
more  easily  than  liquid  ones.  Before  meals  the  foods  lying  in  front 
of  the  cardia  are  to  be  removed  as  completely  as  possible,  especi- 
ally when  a  diverticulum  has  developed. 

In  both  acute  and  chronic  cardiospasm  we  have  obtained  the  most 
permanent  relief  by  the  galvanic  current.  The  length  of  the  esopha- 
gus is  determined  by  methods  devised  by  Penzoldt(7<?<:.  ^/V.)  and  Isert 
Perl,  and  a  rather  large  spiral  electrode  (Stockton's)  is  introduced  to 
a  distance  compelling  it  to  be  in  or  near  the  cardia;  the  anode  is 
placed  on  the  cervical  region,  the  cathode  in  the  cardia,  and  a  cur- 
rent of  25  milliamperes  is  turned  on  for  ten  minutes.  Then  the 
same  procedure  is  repeated  with  the  anode  on  the  epigastrium.  In 
all  cases  where  there  is  any  doubt  about  the  differential  diagnosis 


PYLORIC    SPASM.  643 

between  cardiospasm  and  carcinoma  of  the  cardia,  the  patient 
should  be  examined  under  anesthesia.  If  the  passage  becomes 
readily  permeable  to  the  sound  under  narcosis,  carcinoma  can  be 
excluded. 

In  November,  1896,  we  had  a  girl  patient,  aged  ten  years,  under 
treatment,  where  the  diagnosis  was  difficult  because  the  tube  inevit- 
ably became  caught  above  the  cardia.  As  the  child  could  swallow 
nothing  but  water,  she  became  extremely  emaciated.  For  weeks  we 
supposed  we  were  confronted  with  an  esophageal  diverticulum. 
The  child  was  fed  through  a  tube  which  at  first  we  only  succeeded 
in  passing  under  anesthesia,  but  later  also,  when  the  patient  was 
conscious,  she  was  cured  by  electricity,  the  symptoms  disappearing 
entirely. 

Naturally,  the  inspection  of  the  esophagus  with  the  esophagos- 
cope  would  decide  most  of  such  cases.     (See  p.  175.) 

PYLORIC  SPASM  (Pylorospasm,  Cramp,  Convulsion,  Spasm  of  the 

Pylorus). 

Cramp  of  the  ring  musculature  of  the  pylorus  is  brought  on 
by  entirely  different  causes :  it  may  appear  with  hyperesthesia, 
with  very  strong  chemical  irritation  of  the  mucous  membrane 
of  the  pylorus  by  means  of  hydrochloric  acid  (hyperacidity,  super- 
secretion),  by  excess  of  organic  acids,  as  well  as  with  dilatation  of 
the  stomach  by  gases  (as  a  reflex  neurosis),  and  finally  also  after 
the  caustic  action  of  toxic  substances,  and  further  as  a  secondary 
disease  accompanying  ulcer  and  ulcerating  carcinoma  of  the 
pylorus.  While  the  existence  of  a  secondary  cramp  of  the  pylorus 
is  generally  recognized,  strange  to  say  the  existence  of  a  primary 
cramp  of  the  pylorus,  caused  by  an  independent  motor  neurosis, 
restricted  to  the  pylorus  alone,  is  still  generally  denied.  If  one 
grants,  however,  that  the  insufficiency  of  the  pylorus  may  appear 
also  as  a  genuine  motor  neurosis,  due  to  a  decrease  of  the  irrita- 
bility of  the  motor  nerve  apparatus  of  the  pylorus,  there  is  no  rea- 
son to  deny  entirely  the  occurrence  of  a  primary  cramp  of  the 
pylorus,  which  is  due  to  an  abnormally  increased  irritability  of  the 
motor  nerves,  even  though  this  be  rare.  Indeed,  Stiller,  one  of 
the  most  competent  judges  of  neuroses  of  the  stomach  adduces  a 
primary  cramp  of  the  pylorus  for  the  explanation  of  peristaltic 
unrest  of  the  stomach.  It  is  true  the  detection  of  the  same,  as 
well  as  that  of  the  secondary  spasm,  is  very  difficult,  since  the  most 


644  NEUROSES    OF    THE    STOMACH. 

important  result  of  the  same — namely,  an  increased  peristalsis  of  the 
stomach — can  not  be  proved  with  normal  location  and  size  of  the 
stomach  except  by  Hemmeter's  or  Einhorn's  method.*  However, 
one  may  assume,  with  probability,  a  primary  cramp  of  the  pylorus, 
if  after  the  exclusion  of  the  before-mentioned  causes  (secondary 
cramp  of  the  pylorus),  as  well  as  of  organic  disease  of  the  stomach, 
the  reaction  for  salicyluric  acid  in  the  urine  or  iodin  in  the  saliva 
occurs  much  later  than  under  ordinary  circumstances,  after  the 
introduction  of  i.o  salol  or  o. i  iodoform  into  the  stomach  with  the 
test-breakfast.  The  diagnosis  becomes  probable  also  when  atony 
of  the  stomach  appears  without  any  assignable  cause.  The  results 
of  a  primary  cramp  of  the  pylorus  are  the  same,  naturally,  as  those 
of  the  secondary.  Since  contents  of  the  stomach  can  not  pass  into 
the  intestine  during  the  entire  duration  of  the  spasm,  there  must 
result  a  stagnation  of  the  ingesta  and  a  protracted  burdening  of  the 
stomach,  which  often  causes  atony  of  musculature,  which  can  also 
become  very  easily  exhausted  through  the  energetic  exertions 
for  overcoming  the  increased  resistance  at  the  pyloric  orifice.  If 
the  neurosis  is  very  stubborn,  the  atony  may  pass  over  into  a  pro- 
nounced dilatation,  particularly  if  the  stagnating  ingesta  decompose 
rapidly  and  the  atonic  stomach  is  abnormalh'  distended  with 
gases. 

Therapeutics. — If  a  primary  cramp  of  the  pylorus  is  suspected, 
a  digestible,  non-irritating  diet  is  to  be  prescribed  (see  pp.  219,  220) ; 
every  immoderate  burdening  and  dilatation  of  the  stomach  through 
very  abundant  meals,  which  might  heighten  the  irritability  of  the 
motor  nerves,  is  to  be  avoided.  With  this  the  bromids,  preferably 
the  bromid  of  strontium,  in  liberal  doses  (3.0  (45  grs.)  to  5.0  (75 
grs.)  per  die),  extractum  belladonnse  (0.02  (^  of  a  gr.)  to  0.03  {}4 
of  a  gr.),  and  codein  phosphate  (0.02  (-g-  of  a  gr.)  to  0.03  (j-<  of  a 
gr.))  are  to  be  prescribed.  Electricity  is  a  valuable  adjuvant  to  the 
treatment,  and  should  be  used  in  the  same  manner  as  indicated  for 
cardiospasm.  Spraying  the  pylorus  with  cocain  and  menthol  is  a  sat- 
isfactory treatment.    Under  narcosis  the  pylorospasm  relaxes.    The 

*  In  a  singular  case  of  periodic  pylorospasm  occurring  in  a  hysterical  female  regularly 
at  the  menstrual  period,  we  obtained  a  record  with  our  triple  intragastric  bag  which  may 
be  characteristic  of  these  cases.  This  bag  (A''.  V.  Mid.  Jour.,  June  22,  1895)  records 
the  pyloric,  fundic.  and  cardiac  peristalsis  separately  on  three  tambours  on  the  kymo- 
graph (see  p.  81),  and  in  this  case  the  pyloric  pen  showed  great  spastic  contractions,  and 
tenesmus  lasting  from  three  to  five  minutes  before  thev  relaxed. 


GASTROSPASM. GASTRIC    HYPERPERISTALSIS.  645 

pylorus  may  be  catheterized  by  the  author's  method  of  intubating 
the  duodenum.  This  method  constitutes  a  ready  means  of  recogniz- 
ing pylorospasm.  Kuhn's  method  {loc.  cit.)  is  available  for  the  same 
purpose. 

GASTROSPASM  (CoN\arLSiONS  of  the  Stomach). 
Gastrospasm  is  a  neurosis  in  which  the  musculature  of  the 
stomach  is  so  strongly  contracted  that  the  whole  organ  may  be- 
come hardened  like  a  board,  and  may  be  recognized  by  palpation  as 
a  resistant  mass  through  the  lax  abdominal  integuments.  It  is  a 
very  rare  disease.  Whether  it  ever  occurs  as  an  independent  gen- 
uine neurosis  of  the  motor  apparatus,  or  whether,  as  is  generally 
supposed,  it  occurs  only  as  a  secondary  nervous  affection,  with 
hyperesthesia  of  the  sensory  nerves  of  the  stomach,  or  as  a  conse- 
quence of  a  cramp  of  the  pylorus,  combined  with  hypertrophy  of 
the  musculature  of  the  stomach,  is  still  an  open  question.  In 
the  very  rare  cases  observed  thus  far,  the  single  paroxysms  of 
gastrospasm  invariably  lasted  but  a  short  time,  and  the  quick 
intermission  might  be  sufficiently  explained  by  the  enormous  over- 
exertion of  the  musculature  during  the  attack.  The  treatment  is 
the  same  as  for  hyperperistalsis  (Kussmaul). 

GASTRIC   HYPERPERISTALSIS   (Peristaltic  Unrest   (Kussmaul)— 
Tormina  Ventriculi  Nervosa). 

General  Considerations. — Peristaltic  unrest  is  the  name  given 
by  Kussmaul  to  a  state  of  the  stomach  first  described  by  him,  which 
is  characterized  by  the  appearance  of  extraordinarily  rapid  con- 
tractions of  the  stomach,  following  close  upon  one  another,  which 
appear  especially  after  meals,  continuing  also  during  the  day  and 
sometimes  through  the  night  with  an  entirely  empty  stomach.  This 
excess  of  peristalsis  brings  about  very  disagreeable  sensations  of 
heaving  to  and  fro,  of  unrest,  and  contractions  in  the  region  of  the 
stomach  which,  without  being  really  painful, — as,  for  example,  the 
so-called  cramps  of  the  stomach  with  cardialgia, — may  nevertheless 
annoy  the  patient  very  much.  Only  when  there  is  an  ectasia  or  a 
dislocation  of  the  stomach  present  simultaneously,  as  was  the  case  in 
all  the  observations  up  to  date,  are  these  abnormally  strong  contrac- 
tions of  the  stomach  to  be  seen  and  felt  externally  through  the  lax  ab- 
dominal integument  as  distinct  undulatory  motions.  The  peristaltic 
waves  generally  from  the  fundus  to  the  pylorus  ;  that  is,  from  left  to 


646  NEUROSES    OF    THE    STOMACH. 

right.  Besides  the  peristaltic  motions,  there  were  observed,  in  a  small 
proportion  of  cases,  antiperistaltic  motions  also  ;  sometimes  the  latter 
were  observed  to  exist  alone,  but  this  is  rare  (Schiitz,  Cohn,  Glax). 
If  the  size  and  location  of  the  stomach  are  normal,  the  objective 
symptoms  are  lacking  entirely,  and  only  the  subjective  complaints, 
particularly  the  feeling  of  unrest,  are  evident.  Sometimes,  also,  peri- 
staltic unrest  of  the  small  intestine  co-exists  with  that  of  the  stomach. 

Increased  irritability  of  the  motor  nerves  of  the  stomach  is 
looked  upon  as  the  cause  of  peristaltic  unrest. 

Etiology. — An  abnormally  increased  activity  of  the  stomach 
may  be  brought  about  by  very  dififerent  causes  : 

(i)  As  a  reflex  process,  through  hyperesthesia  of  the  sensory 
nerves  of  the  stomach. 

(2)  By  a  very  strong  stimulation  of  the  mucous  membrane  of 
the  stomach  by  HCl  (hyperacidity,  supersecretion),  by  organic 
acids,  the  result  of  an  abnormal  fermentation  of  the  contents  of 
the  stomach,  by  gases  which  distend  the  stomach  to  a  consider- 
able degree. 

(3)  With  an  advanced  stenosis  of  the  pylorus  and  of  the  duo- 
denum, and,  finally,  it  may  be  due  to  an  increased  irritability  of 
the  motor  nerves,  and  may  thus  be  the  result  of  an  independent 
functional  neurosis. 

The  question  arises.  Which  of  the  motor  nerves  of  the  stomach 
take  part  in  the  merely  functional  illness  in  the  case  of  peristaltic 
unrest  ? 

While  Stiller,  who  has  had  a  large  experience  in  the  domain  of 
neuroses  of  the  stomach,  traces  back  peristaltic  unrest  to  a  cramp 
of  the  ring  musculature  of  the  pylorus,  other  authors  explain  it 
by  an  increased  irritability  of  those  motor  nerves  which  innervate 
the  musculature  of  that  region  of  the  stomach  lying  between  the 
cardia  and  the  pylorus. 

In  severe  cases  the  anomaly  of  function  is  probably  extended 
over  all  the  motor  nerves  of  the  stomach,  since  with  cramp  of  the 
pylorus  alone,  the  peristaltic  motions  are  not  so  intense  as  with 
peristaltic  unrest.  Fleischer  had  opportunity  of  convincing  him- 
self of  this  in  a  case  of  dilatation  of  the  stomach  in  which  the 
greatly  contracted  pylorus  could  each  time  be  felt  distinctly  through 
the  lax  abdominal  integuments. 

With  normal  size  and  location  of  the  stomach  the  peristal- 
tic motions  are  not  visible  in  the  epigastrium,  in  spite  of  the  pres- 


SYMPTOMATOLOGY    OF    PERISTALTIC    UNREST.  64/ 

ence  of  peristaltic  unrest,  on  account  of  the  thickness  of  the 
abdominal  integument  and  because  a  part  of  the  stomach  is  under 
the  liver;  it  is  thus  very  probable  that  many  cases  escape  detection. 
Sexual  excesses,  repeated  emotions,  an  unsuitable  mode  of  living, 
general  nervousness,  as  well  as  anemia,  increase  the  disposition 
to  peristaltic  unrest. 

Symptomatology. — If  a  stomach  which  is  dilated  or  dislocated 
downward  is  seized  with  peristaltic  unrest,  the  symptoms  are,  in 
decided  cases,  so  characteristic  that  they  may  not  easily  be  over- 
looked or  mistaken.  The  very  strong  contractions  of  the  muscles, 
repeating  quickly,  can  be  distinctly  seen  and  felt  as  undulatory 
motions,  especially  when  abdominal  integument  is  relaxed.  If  the 
stomach,  at  the  same  time,  contains  liquids  and  gases,  the  peristal- 
tic waves  are  often  accompanied  by  strong  gurgling  noises  which 
can  be  heard  at  some  distance.  These  undulatory  motions,  caused 
by  restless  action  of  the  muscles,  generally  run  in  the  direction  from 
fundus  to  pylorus  ;  that  is,  from  the  left  above  to  the  right  below, 
more  rarely  also  in  the  reverse  direction  of  right  to  left.  In  some 
cases  only  antiperistaltic  waves  have  been  observed.  By  the  con- 
traction of  the  muscles,  the  fundus  of  the  stomach  may  at  times 
be  distended  to  the  size  of  a  child's  head,  so  that  it  strongly  arches 
the  abdominal  walls. 

After  a  time  the  elevation  sinks,  to  appear  in  another  re- 
gion of  the  stomach.  At  the  height  of  the  contraction  of  the 
muscles  there  may  be  a  slight  circular  constriction  or  furrow  seen 
in  the  middle  of  the  stomach,  dividing  the  organ  into  two  nearly 
equal  parts,  so  that  it  temporarily  assumes  the  shape  of  an  hour- 
glass. 

Since  the  muscular  undulations  can  be  observed  only  with  a 
dilated  or  dislocated  stomach,  they  naturally  extend  beyond  its 
normal  location;  if  peristaltic  unrest  of  the  small  intestine  exists 
simultaneously,  the  undulations  extend  also  over  a  part  of  the  hy- 
pogastric region,  and  even  with  an  empty  stomach  a  rolling  and 
rumbling  noise,  originating  in  the  intestines,  can  be  heard. 

While  energetic  contractions  of  the  stomach  hasten  the  execu- 
tion of  its  normal  functions,  an  excessive  peristalsis  has  a  directly 
injurious  effect,  and  causes  manifold  disturbances  of  digestion. 
Patients  frequently  complain  of  a  lack  of  appetite,  belching,  nausea, 
and  vomiting.  If  the  peristaltic  unrest  is  very  stubborn,  the 
patients  may  suffer  a  loss  in  nutrition,  so  that  the  suspicion  seems 


648  NEUROSES    OF    THE    STOMACH. 

justified  that  malignant  neoplasm  is  developing.  If  the  peristaltic 
unrest  continues  also  through  the  night,  the  state  of  mind  is 
generally  much  depressed,  because  patients  are  constantly  re- 
minded of  their  stomach  and  their  disease;  any  neurasthenia 
which  may  be  present  is  often  considerably  increased.  If  the 
small  intestine  is  also  the  seat  of  active  peristaltic  unrest,  intestinal 
gases  and  liquid  contents  sometimes  regurgitate  into  the  stomach. 
The  eructations  are  then  very  foul-smelling,  and  often  feculent 
masses  are  vomited,  which  may,  exceptionally,  even  contain 
scybala. 

The  demonstration  of  scybala  in  vomited  matter  indicates  that 
the  peristalsis  of  the  colon,  which  generally  is  not  concerned  in 
peristaltic  unrest,  is  considerably  increased.  In  spite  of  peristaltic 
unrest  of  the  small  intestine,  very  stubborn  constipation  and 
meteorism  often  occur,  because  the  colon  is,  as  a  rule,  pacific 
during  these  enteric  contortions. 

With  normal  size  and  location  of  the  stomach,  the  objective  signs 
of  peristaltic  unrest  are  wanting,  and  sometimes  the  disagreeable 
sensations  of  unrest  in  the  region  of  the  stomach  constitute  the 
only  subjective  symptom  of  the  disease. 

Prognosis. — If  the  peristaltic  unrest  is  the  result  of  a  genuine, 
independent,  or  symptomatic  neurosis,  the  prognosis  on  the  whole 
is  favorable.  When  injurious  substances  before  mentioned  are 
kept  away,  and  the  primary  diseases- — neurasthenia,  anemia — can  be 
removed,  the  peristaltic  unrest,  as  a  rule,  soon  recedes  with  suitable 
mode  of  living,  diet,  and  with  methodical  use  of   electricity. 

Diagnosis. — In  order  to  diagnose  that  type  of  peristaltic  unrest 
which  is  an  independent,  genuine  motor  neurosis  with  certainty,  it 
is  necessary  first  to  exclude  those  other  diseases  which  also  cause 
an  increased  peristalsis  of  the  stomach.  The  so-called  cramps  of 
the  stomach  with  cardialgia  are  accompanied  with  more  or  less 
severe  boring,  gnawing,  or  cramp-like  pains,  and,  therefore,  are 
generally  easily  recognized.  Whether  the  increased  peristalsis  is 
the  result  of  a  very  strong  irritation  of  the  mucous  membrane  of 
the  stomach  by  hydrochloric  acid,  organic  acids,  or  by  gases  which 
distend  the  organ  to  excess,  may  generally  be  easily  determined  by 
a  repeated  chemical  analysis  of  the  stomach  contents  ;  further,  the 
gastralgia  sometimes  ceases  entirely  when  the  stomach  has  been 
emptied  by  the  tube  and  is  thoroughly  cleansed  (which  is  not  the 
case  with  peristaltic  unrest).     The  increased  peristalsis  of  dilata- 


THERAPEUTICS    OF    PERISTALTIC    UNREST.  649 

tion  resulting  from  stenosis  of  the  pylorus  or  duodenum  is  also 
arrested  by  lavage.  The  diagnosis  is  very  difficult  with  normal 
size  and  location  of  the  stomach.  In  these  cases  the  author's 
method  of  graphically  recording  the  motor  functions  by  the  deglut- 
able  stomach-shaped  bag  is,  perhaps,  the  only  reliable  means  of 
settling  the  differential  diagnosis  between  peristaltic  unrest  of  the 
stomach  and  that  of  the  intestines.  In  fact,  in  all  neuroses  of  motility 
the  intragastric  stomach-shaped  bag  gives  most  valuable  informa- 
tion of  the  nature  and  intensity  of  the  peristalsis  (see  pp.  76-82). 

One  may  suspect  peristaltic  unrest  when  the  symptoms  recede 
rapidly  after  methodical  application  of  electricity,  and  when  other 
nervous  disturbances  occur  coincidently.  In  the  distinction  of 
peristaltic  unrest  of  the  stomach  from  that  of  the  intestine  one 
should  ascertain  whether  the  rolling  and  rumbling  is  still  audible 
with  an  empty  stomach,  and  whether  the  peristaltic  motions  can 
also  be  perceived  outside  of  the  limits  of  the  stomach.  If,  with  an 
empty  stomach,  every  splashing  noise  is  constantly  absent,  and  if 
the  sounds  appear  again  shortly  after  drinking  water,  this  argues 
for  peristaltic  unrest  of  the  stomach.  If  dilatation  or  dislocation 
of  the  stomach  can  be  excluded,  the  visible  peristaltic  motions  are 
to  be  ascribed  to  the  intestines. 

Leube  has  described  cases  in  which  loops  of  small  intestine 
were  evidently  pushed  up  between  the  stomach  and  the  abdominal 
wall  while  in  active  peristalsis. 

Sedatives,  like  the  bromids,  opium,  and  belladonna,  are  said  to 
exert  a  more  controlling  effect  on  the  intestinal  than  on  gastric 
hyperperistalsis. 

Therapeutics. — The  sufferer  must  be  urged  to  keep  away  from 
injurious  influences,  such  as  sexual  excesses,  mental  shocks,  and 
overexertions,  etc.,  and  lead  a  quiet,  regular  mode  of  life.  If  the 
peristaltic  unrest  is  a  partial  or  resultant  effect  of  a  decided  neuras- 
thenia or  anemia,  a  protracted  sojourn  in  the  country,  in  the 
mountains,  at  the  seashore,  and  hydropathic  procedures  (cold  rub- 
bings, baths),  will  influence  favorably  the  nervous  system  and  the 
composition  of  the  blood;  the  anemia  must  also  be  fought  by  a 
strengthening,  easily  digestible  diet  (scraped  meats),  and  by  iron  and 
arsenic  preparations. 

In  severe  cases  in  which  the  peristaltic  unrest  continues  through 
the  night,  resting  in  bed  and  a  mild  diet  (milk,  soups)  are  recom- 
mended, and  cold  bandages  or  packings  of  the  stomach  should  be 


650  NEUROSES    OF    THE    STOMACH. 

tried,  and  if  these  do  not  relieve,  then  warm  cataplasms.  Every 
immoderate  loading  of  the  gastric  walls,  as  well  as  every  severe 
dilatation  of  the  stomach  by  means  of  gases,  is  to  be  strictly 
avoided,  in  order  not  to  increase  the  irritability  of  the  motor 
nerves.  Kussmaul  attained  very  favorable  results  by  the  internal 
and  external  applications  of  electricity.  In  the  former  case  the 
anode,  by  means  of  the  tube,  is  inserted  into  the  stomach,  par- 
tially filled  with  a  small  quantity  of  a  physiological  common  salt 
solution  (0.6  per  cent.),  and  then  slow  rubbing  motions  are  to  be 
made  with  the  cathode  externally  in  the  region  of  the  stomach ;  in 
external  galvanization  the  anode  is  used  for  the  last-mentioned 
movements,  while  the  cathode  is  placed  on  the  sternum. 

Of  the  medicines,  sodium,  ammonium,  or  strontium  bromid, 
— in  doses  of  three  to  five  gm.  (45  to  75  grs.)  three  times  in 
twelve  hours, — extract  of  belladonna,  dose,  0.008  to  0.013  g^i. 
(i^  of  a  gr.  to  i  of  a  gr.),  or  codein  phosphate,  dose,  0.02  to  0.03 
gm.  ()^  of  a  gr.  to  ^  of  a  gr.),  are  to  be  recommended.  The 
bromid  of  strontium,  20  grs.,  four  times  daily,  has  our  preference. 
Exclusive  feeding  by  the  rectum  for  one  week  is  more  effective 
when  combined  with  rest  in  bed  and  the  use  of  the  bromids.  In  a 
persistent  case  of  peristaltic  unrest  we  obtained  very  good  results 
from  salicylate  of  sodium  .3j,  with  bismuth  subnitrate,  gr.  xvi, 
three  times  daily. 

NERVOUS  ERUCTATION. 
This  is  a  frequent  symptom  in  hysteria,  neurasthenia,  and  allied 
neuropathic  conditions.  It  is  said  to  be  particularly  frequent  in 
the  sexual  neuroses.  The  belching  up  of  tasteless  or  offensive 
gases  is  a  frequent  symptom  in  most  gastric  diseases.  In  fact,  it 
occurs  at  times  in  every  normal  person,  and  then  consists  of  the 
sporadic  expulsion  of  air  that  has  been  swallowed  with  the  food, 
or  of  COo  that  has  been  taken  in  with  beverages,  or  has  been  formed 
by  fermentation  of  the  food.  The  pathological  condition  which 
occurs  in  neurasthenia  consists  of  the  explosive  evacuation  of 
tasteless  gas  in  large  quantities.  The  attacks  are  usually  parox- 
ysmal, and  the  gas  that  is  expelled  is  generally  air  which  is  not 
formed  in  the  stomach  but  which  has  been  swallowed.  Every  time 
air  is  eructated  from  the  stomach  the  closure  of  the  cardia  must  be 
opened,  and  with  a  frequent  repetition  of  this,  apermanent  relaxation 
of  the  cardia  may  develop.    The  muscular  development  of  the  pylorus 


NERVOUS    ERUCTATION.  65  I 

being  much  stronger,  this  orifice  is  not  so  easily  opened  by  gas. 
We  have  known  nervous  individuals,  particularly  hysterical  patients, 
to  belch  up  air  during  the  entire  day,  and  often  during  the  night.  Air 
can  be  aspirated  into  the  stomach  when  the  cardia  is  relaxed  and 
the  esophagus  is  closed,  either  in  consequence  of  a  negative  tho- 
racic pressure  when  the  vocal  cords  are  closed,  or  because  the 
lumen  of  the  stomach  expands  and  dilates  under  nervous  influence. 
On  the  other  hand,  some  nervous  patients  have  the  bad  habit  of 
intentionally  or  unconsciously  swallowing  air  until  the  stomach  is 
expanded,  when  the  same  air  is  eructated  with  explosive  violence. 
In  one  of  the  patients  of  Cartellieri  ( Wiener  allgeineine  vied. 
Zeitung,  1885,  S.  3),  2500  eructations  occurred  in  one  hour.  Some 
patients  have  dyspeptic  symptoms,  while  in  others  digestion 
is  not  disturbed.  We  have  personally  known  a  neurasthenic 
colleague  who  could  eructate  whenever  called  upon  to  do  so. 
It  is  probable  that  in  these  cases  the  air  that  is  swallowed  does 
not  reach  his  stomach,  but  gets  no  further  than  the  upper  part 
of  the  esophagus,  when  it  is  again  expelled.  Oser  has  explained 
the  aspiration  of  air  into  the  stomach,  assuming  that  it  acts 
on  the  principle  of  an  elastic  balloon, — the  contraction  of  the 
longitudinal  muscle  enlarging  the  gastric  lumen  and  thereby 
sucking  in  air,  and  the  circular  muscle  contracting  it  again  and 
thereby  expelling  it.  This  would  not  explain  all  cases,  because 
in  some  hysterical  patients  the  eructation  is  so  rapid  and  uninter- 
rupted that  there  seems  to  be  no  time  left  for  swallowing  air  in  this 
manner.  It  is  probable  that  a  clonic  spasm  of  the  pharyngeal 
muscles  may  exist  here,  persistently  pressing  air  into  the  esoph- 
agus, which  eventually  reaches  the  stomach,  but  generally  is  ex- 
pelled from  the  esophagus.  (Bouveret,  loc.cit.,  "  Aerophagia.") 
Esophageal  eructation  and  vomiting  may  be  produced  by  hysterical 
patients  at  will.  Cartellieri  asserted  that  his  patient  {loc.cit.)  had  no 
time  to  swallow  air  during  the  attack,  and  Ewald  raises  the  ques- 
tion whether  these  attacks  are  really  nervous  eructations,  or  only 
simulate  them. 

Pneumatosis. — This  is  a  condition  of  the  foregoing  disease,  in 
which  the  stomach  is  abnormally  expanded  with  air,  producing  a 
sensation  of  unpleasant  distention  and  dyspnea.  When  the  air 
escapes  into  the  mouth  or  intestines  the  torturing  feelings  cease. 
The  suffering  may  be  permanent  or  only  periodical,  and  has  been 


652  NEUROSES    OF    THE    STOMACH. 

attributed  to  a  spasmodic  closure  of  the  cardia  and  pylorus.  The 
dyspnea  that  occurs  in  these  cases  has  much  similarity  with  the 
"  asthma  dyspepticum  "  of  Henoch.  Pneumatosis  maybe  easily 
recognized  by  an  inspection  and  percussion  of  the  inflated  stomach, 
which,  of  course,  should  be  differentiated  from  a  possible  distended 
transverse  colon.  In  many  cases  persistent  constipation  will  be 
found  to  be  an  etiological  factor,  for  in  these  cases  the  pneumatosis 
rapidly  improves  when  the  bowels  become  regular.  A  possible 
gastric  dilatation  and  atony  must  be  excluded. 

Treatment. — The  patient  and  his  attendants  must  be  in- 
structed that  the  eructation  and  the  pneumatosis  is  largely  a  habit-j- 
and  that  by  close  observation  of  the  patient  he  or  she  can  be 
interrupted  in  the  act  of  swallowing  air,  Penzoldt  cured  a  patient 
of  this  kind  who  had  been  uninterruptedly  swallowing  and  eructat- 
ing air,  by  making  him  keep  his  mouth  open  for  a  half  hour,  as  it  is 
impossible  to  swallow  air  when  the  mouth  is  open.  The  eructation 
ceased  entirely  and  the  patient  became  convinced  that  the  swallow- 
ing of  air  was  the  cause  of  his  suffering.  The  explosive  eructa- 
tions of  hysterical  patients  are  best  treated  by  methods  directed 
toward  the  psychic  condition  of  the  case.  Quincke  has  seen  cures 
by  introducing  a  thick  soft  stomach  tube  and  permitting  it  to  rest 
for  a  while  in  the  esophagus.  The  cases  that  depend  upon  aspira- 
tion by  alternate  expansion  and  contraction  of  the  stomach,  are,  in 
our  experience,  benefited  by  the  intragastric  application  of  the  gal- 
vanic current.  The  neurasthenic  foundation  of  the  disease  should 
receive  careful  attention, — thus  nervous  eructation  and  pneumatosis 
have  been  repeatedly  cured  by  a  course  of  surf  bathing.  Cold 
sponging  and  massage  are  very  useful  aids  in  treatment.  Among 
the  drugs  that  have  been  recommended  are  small  and  frequently 
repeated  doses  of  arsenic,  belladonna,  or  atropia,  hypodermic  injec- 
tions of  morphin,  and  cocain.  Boas  obtained  good  results  from 
the  following  pill : 

IJ.      Extract,  physostigmatis, o.  13         grs.  ij 

Extract,  belladonnse  (Ale), 0.25  grs.  iv 

Strychnin  sulphate, 0.03         gr.  ss.  M. 

Fiant  pill,  No.  XX. 

SiG. — One  pill  thi^ee  times  a  day. 

Spraying  the  pharynx  with  solutions  of  cocain  and  menthol,  and 
the  internal  administration  of  bromid  strontium  are  available  thera- 


NERVOUS,    HABITUAL,    OR    REFLEX    VOMITING.  653 

peutic  measures.  Neurasthenia  depending  on  uric  acid  diathesis 
frequently  causes  nervous  eructations,  for  which  salicylate  of 
sodium  is  of  more  value  than  the  bromids. 

NERVOUS.  HABITUAL,  OR  REFLEX  VO^IITING. 

In  the  classical  experiments  of  Magendie,  the  stomach  of  an 
animal  was  replaced  by  a  pig's  bladder,  and  after  tartar  emetic  was 
injected  into  the  blood,  the  contents  of  the  bladder  were  vomited  ; 
this  experimentor,  accordingly,  concluded  that  the  stomach  had 
nothing  to  do  with  the  act  of  emesis,  but  that  it  was  brought  about 
by  action  of  the  abdominal  muscles.  Tintani,  however,  showed 
later  on  that  the  experiment  of  Magendie  no  longer  succeeds  when 
the  cardia  still  remains  intact  and  is  not  cut  away ;  therefore,  the 
cardia,  inasmuch  as  it  can  prevent  vomiting,  must  be  concerned  in 
the  act  of  emesis,  which  was  found  to  consist  of  firm  closure  of  the 
pylorus,  opening  of  the  cardia,  while  powerful  peristaltic  and  anti- 
peristaltic waves  traveled  over  the  stomach.  The  main  force  for 
emesis  is  then  furnished  by  the  abdominal  muscles,  which  are  ener- 
getically assisted  by  the  contractions  of  the  stomach  itself  There 
are  three  forms  of  nervous  vomiting:  (i)  The  cerebral  or  spinal 
vomiting  (also  known  as  central  vomiting),  which  is  caused  by  di- 
rect or  indirect  stimulation  of  the  vomiting  center  in  the  medulla 
oblongata  from  other  irritated  foci  in  the  brain  and  spinal  mar- 
row. (2)  Nervous  vomiting,  occurring  as  a  symptom  of  hysteria 
or  neurasthenia.  (3)  The  reflex  vomiting,  in  a  more  restricted 
sense,  brought  about  by  reflex  irritations  from  various  other  organs 
in  the  body. 

Cerebral  vomiting  is  a  frequent  symptom  in  organic  diseases 
of  the  brain  and  its  membranes,  particularly  when  they  are  asso- 
ciated with  circulatory  disturbances  or  changes  in  intracranial 
pressure  occurring  more  or  less  suddenly.  It  has  been  observed 
in  acute  inflammatory  processes,  like  encephalitis  and  meningitis, 
also  with  cerebral  abscesses,  tumors,  and  focal  diseases.  It  may 
result  from  acute  anemia  or  hyperemia,  and  after  concussion  of 
the  brain.  It  is  said  to  occur  also  with  vivid  emotional  affections, 
and  after  intoxication  by  opium,  chloroform,  ether,  nicotin,  and 
also  in  uremia.  Spinal  vomiting  in  the  sequence  of  diseases  of  the 
cord  is  rarer,  but  it  is  quite  frequent  in  exophthalmic  goiter  and 
in  tabes  dorsalis,  in  which  it  occurs  in  form  of  the  gastric  crises, 
first  described  by  Charcot.  In  a  majority  of  cases  the  gastric  crises 
43 


654  NEUROSES    OF   THE   STOMACH. 

are  accompanied  not  only  with  severe  vomiting,  but  with  gastric 
hyperesthesia  and  hyperchylia.  According  to  Leyden,  the  vomit- 
ing may  be  absent  entirely.  The  attack  begins  without  any  pro- 
dromal symptoms.  In  the  midst  of  well-being  the  patients  complain 
of  intense  spasm-like  pains  in  the  stomach,  particularly  in  the  epi- 
gastrium, which  radiate  to  the  sides  and  to  the  back.  The  face 
is  pale,  the  pulse  is  small,  soft,  and  rapid,  there  is  vertigo  and 
palpitation  of  the  heart.  The  bowels  are  constipated,  the  ap- 
petite is  lost,  and  thirst  is  great.  At  the  same  time  there  is  great 
prostration  and  weakness  and  a  clinical  picture  of  severe  cojlapse. 
Although  the  patients  drink  large  quantities  of  water,  they  pass 
very  little  urine,  partly  because  the  water  is  again  vomited,  or 
because  it  can  not  enter  the  intestines  on  account  of  an  existing 
pyloric  spasm.  The  abdomen  is  much  retracted  on  account  of 
clonic  contractions  of  the  stomach  and  intestines,  as  well  as  of  the 
abdominal  wall.  Very  soon  copious  vomiting  begins.  First  food, 
then  bile,  mucus,  and  particles  of  blood  are  vomited.  The  reaction 
of  the  vomit  shows  hyperacidity.  After  abundant  vomiting  tran- 
sient relief  is  generally  experienced,  and  in  light  attacks  this  maybe 
the  end  of  the  crisis ;  but  in  severe  attacks  the  vomiting  may  occur 
hourly,  continuing  to  the  evening,  with  very  short  intermissions. 
During  the  night  the  attacks  generally  cease,  to  return  again  on  the 
following  day.  This  course  of  symptoms  may  repeat  itself  in  eight 
to  ten  days,  by  which  time  the  debility  of  the  patient  is  very  great. 
The  suffering  may  cease  just  as  rapidly  and  suddenly  as  it  came. 
The  vomiting  stops,  the  appetite  improves,  and  the  general  condi- 
tion of  the  patient  slowly  convalesces.  If  gastric  crisis  occurs  in  a 
case  of  advanced  tabes,  its  recognition  is  not  difficult,  but  when  it 
occurs  as  one  of  the  very  first  symptoms  of  tabes,  the  correct  diag- 
nosis may  be  very  difficult.  In  that  case  we  must  test  the  patellar 
reflexes,  the  reflexes  of  the  pupil,  Romberg's  symptom,  and  in- 
quire concerning  the  existence  of  lancinating  pains.  In  case  the 
connection  with  tabes  is  not  established,  gastric  crises  may  be  mis- 
taken for  gastroxynsis,  hemicrania,  or  hyperacidity.  Hemicrania, 
intense  one-sided  headaches,  are  rarely  complained  of  in  gastric 
crises.  The  gastric  pains  in  hemicrania  are  insignificant.  Gas- 
troxynsis occurs  only  in  men,  after  severe  mental  exertion  or  after 
well-known  toxic  influences,  and  is  always  incited  by  certain  op- 
portune and  traceable  causes,  which  is  not  the  case  with  gastric 
crisis. 


PERIODICAL    AND    NERVOUS    VOMITING.  655 

Periodical  Vomiting  (Leyden). — This  is  a  combination  of 
symptoms  in  which  the  prominent  feature  is  vomiting  that  returns 
in  regular  intervals.  In  some  cases  the  day  of  the  paroxysm  of 
the  attack  may  be  predicted  with  tolerable  accuracy.  The  attacks 
begin  without  any  marked  prodromal  symptoms,  in  the  midst  of 
apparently  good  health.  Gastralgia  may  introduce  the  attack  or 
may  follow  it.  The  appetite  is  lost,  pulse  small  and  frequent, 
tongue  coated  and  dry.  The  patients  may  have  intense  headache 
and  even  slight  delirium.  The  clinical  picture  is  very  similar  to 
that  of  the  gastric  crisis.  The  character  and  the  reaction  of  the 
vomit  is  essentially  the  same.  The  duration  of  the  attack  varies 
between  twenty-four  hours  and  fourteen  days  ;  some  patients  have 
lancinating  pains  in  the  extremities,  in  place  of  gastralgia.  Toward 
the  end  of  the  attack  the  vomiting  gradually  ceases,  and  the  remain- 
ing complaints  slowly  disappear.  The  characteristic  of  periodical 
vomiting  is  that  the  attacks  occur  at  certain  definite  intervals,  of 
from  two  to  ten  weeks.  The  repetition  occurs  with  great  regularity, 
and  the  disease  may  last  many  years. 

Th.Q  progtiosis  is  therefore  a  very  doubtful  one.  The  distinction 
from  gastric  crisis  is  made  by  the  typical  periodicity,  and  the  pres- 
ence of  great  hyperacidity  of  the  vomit  in  the  crisis.  Periodical 
vomiting  appears  occasionally  as  a  primary,  iodiopathic  neurosis  of 
the  vagi.  It  has  been  known  to  occur  with  hydronephrosis,  with 
floating  kidney,  diseases  of  the  uterus  and  ovaries  with  intestinal 
entozoa,  and  nicotin  poisoning. 

Nervous  Vomiting  in  the  Course  of  Neurasthenia  and  Hys- 
teria.— This  vomiting  is  found  more  frequently  in  hysteria  than  in 
neurasthenia.  If  it  occurs  in  neurasthenia  it  is  associated  with 
marked  sensitiveness  of  the  lower  thoracic  and  the  upper  lumbar 
vertebrae  to  the  electrical  current  (M.  Rosenthal).  The  patients 
frequently  complain  of  severe  pain  in  the  gastric  region,  pointing 
to  a  hyperesthesia  of  the  sensory  nerves,  which  may  probably 
be  the  cause  of  this  kind  of  vomiting.  Stiller  gives  the  fol- 
lowing points  which  are  characteristic  of  vomiting  of  nervous 
origin:  (i)  The  facility  of  the  emesis.  (2)  The  independence  of 
the  quality  and  quantity  of  the  ingesta.  (3)  The  capricious- 
ness  with  which  very  bizarre  articles  of  diet  are  frequently 
retained  to  the  exclusion  of  others.  (4)  Sometimes  the  elec- 
tive vomiting  of  certain  substances  which  seemingly  are  sepa- 
rated   from  the  mixed  chyme.     (5)  The   carelessness  with  which 


656  NEUROSES    OF    THE    STOMACH. 

the  patient  endures  the  habitual  sickness.  (6)  The  tolerance  of 
the  body  to  the  effect  of  inanition  caused  by  the  habitual  vomiting, 
even  when  the  metabolism  is  much  reduced.  (7)  The  extraordin- 
ary influence  of  the  slightest  external  and  internal  causes  that  act 
on  mood  or  temperament.  (8)  The  frequent  occurrence  of  emesis 
when  no  food  has  been  taken  and  the  stomach  is  apparently  empty. 
(9)  The  presence  of  other  nervous  symptoms  alternating  or  con- 
temporaneous with  the  vomiting.  To  these  Boas  adds  (10)  the 
absence  of  important  secretory  or  motor  disturbances.  In  some 
of  these  cases  the  vomiting  occurs  almost  every  day,  occasionally 
after  each  meal.  In  other  cases  the  attacks  occur  at  longer  or 
shorter  intervals,  either  spontaneously  or  after  severe  influences 
exerted  upon  the  psychic  sphere.  Cases  have  been  repeatedly 
observed  in  which  only  the  liquids  have  been  expelled,  and  in  others 
only  the  solids.  Sometimes  the  vegetable  and  carbohydrate  foods 
are  vomited  and  proteid  food  retained,  or  vice  versa.  Nausea  and 
retching  are  absent  in  the  vomiting  of  hysterics,  which  occurs  with- 
out any  exertion. 

Juvenile  vomiting  rarely  occurs  by  itself,  but  is  rather  an  expres- 
sion of  a  dyspepsia  developed  in  school-children  as  a  result  of 
mental  overexertion.  The  symptoms  are  the  following :  dyspeptic 
complaints,  gastralgia,  vomiting,  great  pallor,  dilatation  of  pupils, 
slowing  of  the  pulse,  constipation.  In  all  of  these  cases  improve- 
ment follows  when  the  children  are  removed  from  school  and 
allowed  to  rusticate  in  the  fresh  country  air  (Leyden, "  Ueber  period. 
Erbrechen,"  etc.,  Zeitschr.f.  klin.  Med.,  1882,  Bd.  iv,  S.  605). 

Reflex  Vomiting  in  a  More  Restricted  Sense. — Strictly 
speaking,  vomiting  is  most  always  a  reflex  act,  and  the  separation 
of  other  forms  of  vomiting  from  reflex  vomiting  is  justifiable  only 
on  didactic  grounds  (Fleiner).  There  is  hardly  an  organ  which 
could  not  produce  this  form  of  vomiting  when  it  is  in  a  state  of 
irritation.  The  peripheral  irritations  which  cause  this  reflex  vomit- 
ing are,  among  the  first,  those  which  strike  the  sensory  and  motor 
nerve-endings  in  the  esophagus,  the  posterior  pharyngeal  wall,  the 
epiglottis,  the  soft  palate,  and  the  root  of  the  tongue.  All  organs  that 
are  supplied  by  branches  of  the  vagus — so  particularly  the  abdominal 
organs — may,  under  pathological  conditions,  excite  an  attack  of  reflex 
vomiting.  It  may  occur  as  a  result  of  constipation,  meteorism,  lead 
colic,  irritations  by  foreign  bodies,  and  intestinal  parasites.  It  is  one 
of  the  first  symptoms  of  strangulated  hernia,  and  of  conditions  of 


REFLEX    VOMITING.  657 

irritation  in  the  peritoneum.  Abscess  of  the  liver,  perityphlitis, 
renal  and  hepatic  colic  are  associated  with  reflex  vomiting.  It  has 
been  known  to  occur  by  the  invasion  of  the  ascaris  lumbricoides 
into  the  ductus  choledochus.  Emboli  in  the  kidney,  liver,  pancreas, 
and  spleen,  floating  kidney,  and  severe  concussion  or  contusion  of 
any  abdominal  organ  have  been  known  to  cause  reflex  vomiting. 
Diseases  of  the  female  sexual  organs  are  a  prolific  source  of  this 
form  of  emesis.  It  is  not  the  severe  anatomical  diseases  of  these 
organs  that  most  often  cause  these  attacks,  but  preferably  the  slight, 
inconsiderable  affections.  Normal  menstruation  and  pregnancy  are 
occasionally  accompanied  by  emesis.  The  so-called  pernicious 
vomiting  of  pregnancy  may  be  caused  by  a  variety  of  conditions, 
although  its  pathogenesis  is  still  obscure.  When  vomiting  is  uncon- 
trollable in  a  female  in  whom  the  evidences  of  pregnancy  are  unmis- 
takable, the  embryo  should  be  removed  and  the  uterus  curetted 
before  prostration  becomes  too  great.  Fleischer  states  that  this 
should  be  done  in  order  to  save  the  life  of  the  mother  and  eventually 
that  of  the  child  {loc.  cit.,  p.  977);  the  pernicious  vomiting  of  preg- 
nancy occurs,  however,  at  such  an  early  period  in  our  experience  that 
the  child  would  not  be  viable.  Every  form  of  severe  vomiting,  when 
it  continues  for  a  week  or  more,  will  eventually  produce  hemate- 
mesis  from  local  ischemias  produced  by  the  convulsive  gastric 
contractions  during  the  emesis.  In  a  case  that  died  at  the  Mary- 
land General  Hospital  in  April,  1897,  the  young  woman,  who  was 
undoubtedly  pregnant,  and  who  refused  to  be  curetted,  vomited 
and  purged  blood  in  the  second  week  so  that  the  practitioner  who 
presented  her  for  admission  stated  that  she  had  undoubtedly  a  gas- 
tric ulcer.  At  the  autopsy,  which  occurred  three  weeks  after  the 
beginning  of  the  attack,  an  embryo  between  two  and  three  months 
old  was  found  within  the  uterus,  while  nowhere  in  the  stomach  could 
a  lesion  be  found  excepting  large  ecchymoses,  some  of  them  attain- 
ing the  size  of  a  five-cent  piece,  and  scattered  over  the  entire  surface 
of  the  stomach.  Displacements  of  the  uterus,  pelvic  exudates,  para- 
metritis, inflammations  and  ulcerations  of  the  uterine  mucosa, 
myomata,  and  ovarian  diseases  may  cause  reflex  vomiting,  which  is 
much  rarer  with  the  diseases  of  the  male  sexual  organs.  Never- 
theless, it  is  occasionally  observed  with  injury  or  inflammations  of 
the  testicles  and  in  epididymitis.  Chronic  inflammation  about  the 
nasal  mucous  membrane,  polypi,  and  hyperplasia  of  the  upper  air- 
passages  have  been  recorded  as  producing  the  disease.     Eichhorst 


658  NEUROSES    OF    THE    STOMACH. 

has  repeatedly  observed  reflex  vomiting  in  certain  individuals  on 
hearing  very  shrill  tones.  Von  Troeltzsch  has  called  attention  to  the 
fact  that  irritation  of  the  external  auditory  canal  may  cause  emesis. 

Prognosis  of  Nervous  Vomiting. — The  prognosis  will  vary 
with  the  fundamental  causative  disease.  Gastric  crises,  when  they 
occur  in  advanced  tabes,  may  cease  entirely  after  a  time  and  remain 
away,  although  the  fundamental  disease  continues  and  even  be- 
comes worse.  Periodical  vomiting,  which  occurs  after  insignifi- 
cant disturbances  in  other  organs,  which  get  well  without  difficulty, 
may  stubbornly  persist  after  the  fundamental  disease  has  been 
cured.  The  prognosis  is  favorable  wherever  the  causes  can  be 
recognized  and  completely  removed. 

Diagnosis. — The  majority  of  the  forms  of  nervous  vomiting  can 
be  determined  after  an  exhausting  examination  of  the  entire  body, 
the  urine,  the  blood,  and  gastric  contents.  A  careful  study  of  the 
previous  history  is  indispensable.  Nervous  vomiting,  as  we  have 
already  said,  may  be  in  rare  cases  an  idiopathic  vagus  neurosis 
(Leyden),  but  in  most  cases  some  palpable  cause  for  the  vomiting 
can  be  detected.  Prominent  among  these  are  dislocated  kidneys, 
hydronephrosis,  uterine  and  ovarian  diseases,  entozoa,  and  nicotin 
poisoning.  A  careful  examination  of  the  fundus  of  the  eyes,  of  the 
ears,  and  of  the  nose,  mouth,  pharynx,  and  larynx  should  never  be 
omitted. 

Treatment. — Whenever  possible,  the  treatment  must  be  directed 
to  the  underlying  causal  disease.  Only  when  the  various  morbid 
states  of  other  organs  which  have  been  mentioned  in  the  etiology 
and  symptomatology  can  be  excluded  after  application  of  all 
methods  of  diagnostic  technic,  only  then  is  a  purely  symptomatic 
treatment  justifiable.  Hysteria  and  neurasthenia  are  to  be  met  by 
hydropathic  procedures,  or  by  absolute  rest,  abstention  from  mental 
and  emotional  excitement,  and  a  sojourn  in  the  mountains  or  at 
the  seashore.  In  most  cases  the  greatest  possible  rest,  and  strict 
avoidance  of  psychic  disturbances  will  be  indispensable.  Gastral- 
gic  pains  and  hyperesthesia  can  be  relieved  by  a  hot  cataplasm  on 
the  stomach,  but  the  application  of  the  galvanic  current  anode  on 
the  stomach,  or  in  the  stomach,  and  cathode  alternately  on  the 
sternum  or  spinal  column  will  be  more  efficacious.  The  internal 
gastric  douching  with  warm  water,  and,  as  we  have  found,  spraying 
of  the  inside  of  the  stomach  with  solutions  of  menthol  and  cocain, 
are  also  generally  followed  by  cessation  of  the  pain.     In  vomiting 


TREATMENT    OF    NERVOUS    VOMITING.  659 

of  pregnancy,  rectal  feeding  and  six  grains  of  the  basic  orexin  in  a 
gelatin  capsule  three  to  four  times  a  day  should  be  tried  first, 
but  curetting  of  the  uterus  should  not  be  delayed  too  long.  The 
following  formula  we  have  found  efficacious  in  the  treatment  of 
this  form  of  vomiting  of  the  non-pernicious  type : 

U.     Cerii  oxalatis, 4.0       gr.  Ix 

Cocain  hydrochlor.,      0.20     gr.  iij 

Menthol, 0.80     gr.  xij 

Bismuth  salicylatis, ■  .    .    .       4.0       gj 

Elixir  simpl., q.  s 180.0    f^vj.  M. 

SiG.— f^ss  on  an  empty  stomach  four  times  daily. 

The  idiosyncrasy  of  the  patient  concerning  diets  should  be  care- 
fully studied.  A  priori,  "  no  diet  can  be  suggested  that  shall  be 
universally  applicable  to  all  cases."  The  ingestion  of  liquids  must, 
as  a  rule,  be  very  much  limited,  and  thirst  relieved  by  colon  enemata. 
If  every  meal  is  vomited  it  is  best  not  to  permit  the  ingestion  of 
larger  quantities  of  food,  but  simply  to  give  nourishment  in  very 
small  quantities — iced  milk,  champagne,  cold  tea  or  coffee,  or  egg- 
albumen  with  brandy,  or  clam  bouillon  in  tablespoonful  doses. 
Superacidity  must  be  treated  according  to  principles  laid  down  in 
the  chapter  on  this  subject.  When  there  is  abnormal  hyperesthesia 
of  the  stomach,  it  is  well  to  feed  the  patient  by  rectal  enemata  for 
about  a  week  to  ten  days  according  to  methods  described  in  the 
chapter  on  Dietetics.  The  most  effective  sedative  that  we  have  is 
morphin,  particularly  the  hypodermic  injection  of  ^^^  of  a  grain 
together  with  y^  of  a  grain  of  atropin  sulphate.  The  following 
suppositories  are  useful  where  we  do  not  wish  to  create  an  adapta- 
tion to  morphin: 

R .      Extract,   belladonnas, 0.20         gr.  iij 

Codein  phosphatis, 0.80         gr.  xij 

Butyr.  cacao, q.  s. 

Supposit.  No.  XII. 

SiG. — Insert  one  suppository  every  two  hours  during  the  attack. 

When  the  nervous  vomiting  persists,  even  during  the  night,  the 
bromids,  together  with  chloral  hydrate,  are  of  approved  efficacy. 
We  are  in  the  habit  of  giving  30  grs.  of  bromid  of  strontium 
with  15  grs.  of  chloral  in  peppermint  water,  repeated  every  three 
hours  until  sleep  supervenes.  We  have  also  found  the  following 
combination  to  be  a  reliable  means  of  combatting  this  neurosis  : 


66o  NEUROSES    OF   THE   STOMACH. 

R.      Menthol, I.o  grs.  xv 

Cocain  hydrobromatis, 0.4  grs.  vj 

Aquas  chloroformi, 120. o  f,^iv 

Spir.  vini.  gallic, 60.0  f^ij. 

SiG. — One  tablespoonful  three  times  a  day.  M. 

In  the  treatment  of  the  gastric  crises  Boas  has  found  that 
iodid  of  potassium  and  bromid  of  sodium  exert  very  favorable 
influences  in  diminishing  the  frequency  and  intensity  of  the  attacks. 
The  use  of  the  constant  current,  with  the  anode  within  the  stomach 
and  the  cathode  over  the  spinal  cord  in  the  cervical  region,  is  gene- 
rally followed  by  a  very  marked,  palliative  effect.  Chloroform,  three 
to  five  drops  given  on  sugar,  ammoniated  tincture  of  valerian,  25 
drops  p.  r.  n.,  and  the  compound  spirits  of  ether,  15  to  20  drops 
p.  r.  n.,  might  be  tried,  but  in  our  experience  they  are  rarely  effica- 
cious. 

INSUFFICIENCY  OR  INCONTINENCE  OF   THE  CARDIA. 

Incontinence  of  the  cardia,  due  to  paresis  or  paralysis  of  the 
motor  nerves  of  the  ring  muscle,  is  a  comparatively  rare  malady, 
though  somewhat  more  frequent  than  that  of  the  pylorus.  It 
appears  either  as  an  independent  disease,  or  as  a  partial  or  result- 
ant phenomenon-of  other  neuroses.  The  relaxation  of  the  cardia 
produces  an  effect  directly  opposite  to  that  of  cramp  of  the  cardia. 
While  the  latter,  as  is  well  known,  prevents  the  removal,  by  eruc- 
tation, of  the  air  and  gases  introduced  into  the  stomach  during  meals, 
as  well  as  that  of  liquid  or  solid  contents  of  the  stomach,  insuffici- 
ency of  the  cardia,  on  the  other  hand,  much  facilitates  it.  When 
the  relaxation  of  the  cardia  is  accompanied  by  an  increased  irri- 
tation of  those  motor  nerves  which  innervate  the  dilator  of  the 
cardia,  so  that  by  the  spasm  of  the  latter  the  esophageal  orifice 
of  the  stomach  is  actively  enlarged,  energetic  peristalsis  of  the 
stomach,  with  the  additional  influence  of  the  abdominal  pressure, 
will  raise  portions  of  the  gastric  contents  into  the  esophagus,  and 
even  into  the  mouth. 

The  firmness  of  the  cardial  closure,  even  under  normal  circum- 
stances, seems  to  vary  greatly  in  different  individuals.  While  many 
persons  vomit  only  with  difficulty, — since  the  resistance  at  the 
esophageal  orifice  of  the  stomach  is  greater,  so  that  they  have  to 
make  use  of  almost  all  known  remedies  and  devices  in  order  to  over- 
come it, — and  eject  only  a  portion  of  the  contents  of  the  stomach, 


REGURGITATION.  66 1 

others  vomit  with  exceeding  ease,  and  they  succeed,  with  only  a 
moderate  contraction  of  the  abdominal  muscles,  in  emptying  the 
stomach  entirely  through  vomiting.  In  one  and  the  same  indi- 
vidual the  closure  of  the  cardia  may  vary  at  different  times.  At 
times  small  quantities  of  ingesta  come  up  again  into  the  mouth 
after  eating,  while  at  other  times,  with  the  same  food  and  the 
same  fullness  of  the  stomach,  this  does  not  occur. 

If  only  small  quantities  of  the  contents  of  the  stomach  come  up 
into  the  mouth,  now  and  then,  this  does  not  yet  constitute  an  abnor- 
mal condition  ;  the  latter  exists  only  then  when  large  quantities  of 
ingesta  come  up  after  eating,  and  when  this  is  repeated  frequently, 
almost  regularly  every  day  for  a  considerable  period  of  time.  If  the 
masses  which  come  up  are  expectorated,  the  whole  process  is  called 
regurgitation;  but  if,  on  the  other  hand,  they  are  swallowed  again, 
it  is  called  rumination  (merycism,  remastication),  even  when  the 
regurgitated  foods  are  not  chewed  again,  which  is  observed  in  a 
small  number  of  patients. 

Concerning  the  causes  of  regurgitation  and  rumination,  opinions 
still  differ  greatly  at  the  present  time.  Some  authors  trace  both 
conditions  to  a  permanent  relaxation  of  the  cardia,  but  the  presence 
of  the  deglutition  sounds  is  an  argument  against  a  permanent  incon- 
tinence, according  to  Ewald  ;  other  authors  assume  a  temporary 
insufficiency  of  the  cardia,  and  still  others,  in  addition,  an  increased 
irritation  of  the  motor  nerves — and  eventually  also  of  the  sensory 
nerves — of  the  stomach.  According  to  M.  Rosenthal,  regurgitation 
and  rumination  are  caused  by  an  increased  irritability  of  the  vagus, 
and  with  this  also  an  increased  irritability  of  the  motor  nerves  lead- 
ing from  it  and  supplying  the  dilator  cardise,  which  causes  a  spasm 
of  the  latter,  and  through  this  an  active  enlargement  of  the  esopha- 
geal orifice  of  the  stomach.  Whether  the  disease  is  of  central  or 
peripheral  origin  is  at  present  also  impossible  to  decide. 

Regurgitation. — At  a  longer  or  shorter  period  after  meals  large 
quantities  of  the  liquid  and  solid  contents  of  the  stomach  are  at 
first  involuntarily  brought  up  again  into  the  mouth  and  are 
then  expectorated.  With  protracted  duration  of  regurgitation 
the  patient  generally  learns  how  to  facilitate  the  ascension  of  the 
ingesta  by  means  of  rather  severe  contractions  of  the  musculature 
of  the  abdomen.  According  as  regurgitation  takes  place  in  the 
first  or  second  period  of  the  digestion  of  the  stomach,  the  regurgit- 
ated food  particles  have  either  the  same  taste  as  in  eating,  or  they 


662  NEUROSES    OF    THE    STOMACH. 

taste  sour  (HCl)  or  bitter  (peptone).  Regurgitation  is  not  easily 
mistaken  for  vomiting,  since  the  sensations  of  nausea  experienced 
before  and  after  the  latter  are  entirely  lacking  with  regurgita- 
tion. Regurgitation  takes  place  without  any  especial  exertion 
on  the  part  of  the  patients,  and  is  easily  distinguished  from  the 
retching  forth  of  foods  previously  eaten,  in  cases  of  stenosis  or 
the  formation  of  diverticula  in  the  esophagus — that  is,  from  the  ris- 
ing up  of  the  same  into  the  mouth,  when  the  diverticulum  is  full 
and  runs  over.  The  difficulties  of  deglutition,  the  result  of 
sounding  the  esophagus,  as  well  as  the  constant  absence  of  hydro- 
chloric acid  in  the  regurgitated  masses,  make  a  sure  differentiation 
of  the  two  first-mentioned  diseases  possible.  Most  patients  are 
able  to  suppress  regurgitation,  but  in  a  few  cases  they  do  not 
succeed  in  this,  however  much  they  try.  If  copious  quantities 
of  the  contents  of  the  stomach  are  regurgitated  in  quick  suc- 
cession and  are  expectorated,  the  general  nutrition  may  suffer 
considerably ;  but  generally  these  patients  have  a  very  hearty 
appearance.  Other  nervous  disturbances — signs  of  hysteria  or 
neurasthenia — may  be  present  coincidently.  With  protracted  dura- 
tion, regurgitation  may  develop  into  rumination. 

The  prognosis  is  generally  favorable  with  regurgitation,  since  the 
state  of  nutrition  remains  good,  and  if  disturbances  of  nutrition 
appear,  the  patient  often  can  be  induced  to  swallow  the  ingesta 
which  has  risen  into  the  mouth  and  to  energetically  prevent  its 
coming  up  again. 

Therapeutics. — Regurgitation  is  promoted  by  hasty  eating  and 
quick  swallowing  of  insufficiently  chewed  foods,  especially  when 
the  latter  are  of  difficult  digestion;  a  diet  should,  therefore,  be  pre- 
scribed which  is  easily  digestible,  and  the  patients  should  be 
directed  to  eat  slowly  and  chew  thoroughly.  Gladstone's  sug- 
gestion is  to  give  each  morsel  of  food  one  bite  or  grind  for  every 
tooth  in  the  mouth, — /.  ^.,  32, — before  it  is  swallowed.  It  is  best 
for  the  patients  to  eat  in  the  company  of  such  persons  whose  good 
opinion  they  value,  so  that  they  avoid  expectorating  the  ingesta 
which  has  risen  into  the  mouth,  and  will  rather  swallow  it 
again,  endeavoring  to  combat  regurgitation  to  the  utmost  of  their 
power.  If  indications  of  hysteria  or  neurasthenia  can  be  shown, 
these  diseases  are  first  to  be  treated.  In  stubborn  cases  the  swallow- 
ing of  small  pieces  of  ice  is  recommended  (Alt),  which  may  reflexly 
induce  the  musculature  of  the  cardia  to  contract.     In  addition,  mas- 


RUMINATION    OR    MERYCISM.  '  663 

sage  of  the  epigastrium,  internal  and  external  galvanization  and 
faradization,  as  well  as  internal  administration  of  strychnin  nitr. 
(0.003  :  0.006)  are  indicated.  The  galvanic  current  should  .be 
applied  in  the  same  manner  as  in  cardiospasm. 

RUMINATION  OR  MERYCISM. 

Patients  afflicted  with  this  neurosis  return  the  ingesta  from  the 
stomach  through  the  esophagus  back  into  the  mouth  sooner  or 
later  after  they  have  been  swallowed.  This  is  not  only  done  without 
nausea,  but  apparently  with  a  certain  enjoyment.  The  raised  food 
is  rechewed,  and  either  swallowed  again  or  expectorated.  This  occurs 
habitually  several  hours  after  meals  and  without  the  least  exertion. 
Rumination  in  the  human  subject  has  been  known  for  a  long  time. 
Fabricius  Ab.  Aquapendente  described  the  disease  in  1618.  As 
the  knowledge  of  physiology  of  older  practitioners  was  very 
limited,  and  they  had  no  conception  of  the  functions  and  mechanism 
of  gastric  digestion,  the  most  peculiar  hypotheses  were  developed 
in  explanation  of  this  very  interesting  neurosis.  It  was  firmly 
believed  that  ruminants  descended  from  parents  with  horns,  or  that 
they  at  least  had  a  horned  father,  or  had  been  nursed  from  the 
udder  of  ruminating  horned  animals.  It  was  also  believed  that  the 
stomach  of  human  ruminants  was  divided  into  several  sections  by 
partitions,  as  we  find  them  in  cattle.  After  it  was  found  at  autop- 
sies that  ruminants  possessed  stomachs  like  all  other  human  beings, 
the  profession  gradually  accepted  the  neurotic  explanation  of  the 
malady. 

Etiology. — A  neuropathic  constitution  is  a  frequent  factor  in  the 
development  of  rumination.  Heredity  seems  to  have  some  effect 
in  the  matter,  as  ruminating  fathers  have  been  known  to  have  rum- 
inating children.  The  element  of  imitation  and  suggestion  can, 
however,  not  well  be  eliminated  under  this  question  of  heredity. 
Freund  and  Korner  have  described  a  case  in  which  two  children 
developed  this  habit  in  imitation  of  their  ruminating  governess. 
The  disease  seems  to  be  more  frequent  in  men  than  in  women.  It 
occurs  in  all  classes  of  society  and  at  all  ages.  The  following  are 
some  of  the  causes  assigned  to  rumination.  Sexual  excesses,  mastur- 
bation, fear,  terror,  anger,  psychic  irritations,  and  the  very  hasty 
deglutition  of  badly  masticated  food,  particularly  when  it  exists 
exclusively  of  vegetables,  injury  to  the  epigastrium,  achlorhydria, 
obstinate  constipation,  and  gastro-enteritis.     It  is  claimed  by  Dehio 


664  NEUROSES    OF    THE    STOMACH. 

that  whooping-cough  may  be  followed  by  this  disease ;  this  is  very 
plausible,  because  pertussis  brings  on  frequent  vomiting,  and  there- 
by an  incontinence  of  the  cardia.  The  majority  of  ruminating  patients 
belong  to  the  class  of  neurasthenics,  and  hysterical,  hypochon- 
driacal, epileptic,  anemic,  choreic,  and  idiotic  individuals.  The 
disease  has  been  studied  by  Bourneville  and  Seglas,  Dehio,  Alt, 
Boas,  Bear,  Ducasse,  Decker,  Einhorn,Oser,  P6nsgen,Johannessen, 
Lebert,  M.  Rosenthal,  and  E.  Singer. 

In  the  N.  Y.  Med.  Record  for  June  12,  1896,  Dr.  H.  A.  Minas- 
sian  reports  an  interesting  case  of  merycism  with  achlorhydria  and 
hyperperistalsis  which  was  cured  by  hydrochloric  acid,  exclusion  of 
fluids,  and  exercise  of  self-control.  In  the  same  journal  for  July  10, 
1897,  Andrew  Halliday,  M.B.,  a  physician  of  Nova  Scotia,  who 
personally  has  the  power  of  regurgitation  and  rumination  at  will, 
gives  the  analysis  of  his  own  stomach  contents  :  Forty-five  to  sixty 
minutes  after  a  Ewald  test-meal  the  total  acidity  was  45  to  55. 
The  free  HCl  0.124  to  0.1604  per  cent.  His  motility  seems  normal. 
These  two  cases  suffice  to  show  the  variability  of  the  state  of  secre- 
tion and  motility  in  merycism. 

Symptomatology. — The  regurgitation  of  ingesta  from  the 
stomach  into  the  mouth  is  usually  at  first  voluntary,  but  later  on 
involuntary.  The  rumination  differs  from  simple  regurgitation,  in 
that  the  raised  food  is  expectorated  in  the  latter  disease,  but  is  swal- 
lowed again  in  the  former.  The  ascent  of  the  food  from  the 
stomach  causes  a  pleasurable  sensation  to  these  patients,  and  they 
assist  the  act  by  bringing  into  effect  the  pressure  of  their  abdominal 
muscles.  In  severe  cases  the  rumination  occurs  after  every  meal, 
and  lasts  either  only  for  the  first  hour  or  for  five  or  six  hours. 
The  condition  of  the  secretory  function  is  variable.  Jiirgensen  found 
no  free  HCl,  Bear  and  Boas  found  subacidity,  while  Alt  demon- 
strated hyperacidity  in  one  of  his  cases.  In  some  patients  secretion 
was  found  to  be  normal.  In  one  of  the  cases  observed  by  us  we 
found  that  the  state  of  the  secretion  varied,  as  expressed  in  the 
chemical  analysis  of  the  raised  masses  according  to  the  time  after 
the  ingestion  in  which  they  were  regurgitated.  If  they  were 
regurgitated  immediately  after  the  meal  they  were  alkaline,  con- 
tained no  free  HCl  nor  ferments  which,  however,  were  present 
within  forty-five  minutes  of  the  first  ingestion  of  food.  It  is  prob- 
able that  many  of  the  discrepancies  concerning  the  state  of  the 
secretion,  as  stated  by  the   various  authors  mentioned,  can  be  ex- 


SYMPTOMATOLOGY    OF    RUMINATION.  665 

plained  on  the  same  grounds.  Alt  has  suggested  a  very  interesting 
theory  in  explanation  of  the  ruminating  habit  {Berlin,  klin.  Woch- 
ensclir.,  88,  Nos.  26  and  27) :  he  suggests  that  the  object  of  the  act 
may  be  the  correction  of  defective  chewing  and  insalivation  of 
the  food,  and  the  hyperacidity  caused  thereby.  Acting  accordingly, 
Alt  treated  his  patient  with  alkalies,  and  claims  to  have  found  that 
the  case  ruminated  less  frequently  and  by  and  by  could  suppress 
the  habit.  Boas  {Berlin,  klin.  Wochenschr.,  1886,  No.  831)  has  pub- 
lished a  case  of  rumination  with  subacidity,  and  in  this  case 
improvement  followed  the  administration  of  HCl.  According  to 
Einhorn,  but  106  cases  of  this  malady  have  been  described  up  to 
1896,  which  cases  occurred  chiefly  among  the  professional  and  edu- 
cated classes — physicians,  lawyers,  and  philologists.  This  observa- 
tion was  also  made  in  a  report  by  Johannessen  {Zeitschr.f.  klifi.  Med., 
Bd.  X,  S.  274).  The  following  is  a  brief  account  of  a  case  occurring 
in  our  private  practice.  M.  F.,  age  thirty-eight,  mother  has  been  a 
highly  nervous  woman,  much  afflicted  with  insomnia  and  neuralgia  ; 
father  died  at  the  age  of  fifty-six  from  Bright's  disease.  He  was  a 
very  irascible  and  eccentric  man.  M.  F.  has  had  no  severe  disease, 
except  gout  four  years  ago.  He  is  a  pianist  of  exceptional  ability, 
and  has  played  in  foreign  countries  as  well  as  in  the  larger  cities 
of  the  United  States.  Ordinarily  and  when  in  a  quiet  frame  of 
mind  he  rarely  ruminates,  but  when  he  gives  instruction,  particu- 
larly when  he  has  to  play  at  a  concert,  or  at  other  times  when  he 
is  emotionally  excited  or  disturbed,  he  begins  to  raise  food  into  his 
mouth,  which  he  at  first  swallows  for  about  two  hours.  He  con- 
fesses that  he  chews  the  food,  and  actually  enjoys  it,  but  at  the 
expiration  of  two  hours  the  muscles  of  mastication  become  so  ex- 
hausted that  he  can  no  longer  chew  the  raised  masses.  He  would 
then  like  to  put  an  end  to  the  ruminating,  or  rather  to  the  rising  of 
the  food,  but  then  can  not  stop  it  as  it  persists  in  coming  up  from 
his  stomach.  He  then  terminates  the  rumination  by  voluntarily 
evacuating  his  stomach  through  vomiting,  which  he  accomplishes 
very  easily. 

The  masses  begin  to  ascend  within  ten  to  fifteen  minutes  after  a 
meal,  and  are  then  alkaline.  He  is  also  aware  that  they  begin  to 
taste  salty  sour,  as  he  calls  it,  forty-five  minutes  to  an  hour  after 
the  meal.  The  total  acidity  one  hour  and  a  quarter  after  a  meal, 
as  judged  from  the  regurgitated  masses,  is  70°.  Free  HCl  30°, 
erythrodextrin  present.     Achroodextrin  present.     Gastric  motility, 


666  NEUROSES    OF   THE   STOMACH. 

as  determined  by  Hemmeter's  method,  is  plainly  exaggerated. 
Physical  examination  of  the  thoracic  and  abdominal  organs  nega- 
tive. Urine  negative.  Examination  of  blood  negative.  On  one 
occasion  this  patient  had  not  ruminated  for  three  weeks,  when  he 
had  to  fulfil  an  engagement  at  a  concert.  The  author,  for  the  sake 
of  study,  was  present  when  he  took  his  supper  on  the  evening  of 
this  concert.  Within  fifteen  minutes  after  the  supper  we  observed, 
by  the  movements  of  his  throat,  he  had  begun  his  old  bad  habit, 
which  kept  up  during  the  entire  evening,  and  was  plainly  observ- 
able while  he  was  performing  at  the  piano  during  the  concert. 

Atony  and  dilatation  may  be  present,  together  with  rumination, 
and  the  state  of  the  motility  seems  to  vary  as  much  as  that  of 
secretion.  The  general  nutrition  is  not,  as  a  rule,  affected,  although 
the  disease  may  have  existed  a  long  time ;  but  when  the  patients 
persistently  spit  out  the  ascending  masses  of  food,  instead  of  swal- 
lowing them  again,  or  when  severe  disturbances  of  secretion  and 
motility  exist,  the  patients  rapidly  lose  strength  and  weight. 
According  to  von  Hacker  and  G.  Singer,  there  is  an  insufficiency  of 
the  cardia  and  a  dilatation  of  the  esophagus  immediately  above  the 
cardia,  which  has  been  caused  by  mechanical  expansion,  resulting 
from  the  regurgitation  of  large  bits  of  food.  This  esophageal 
expansion  has  been  demonstrated  by  these  authors  with  the  esoph- 
agoscope. 

Prognosis. — This  is  not  a  serious  disease,  as  the  general  nutri- 
tion remains  good,  and  if  the  patient  really  does  begin  to  suffer  he 
may  be  relieved  by  a  rational  psychic  and  symptomatic  treatment, 
particularly  if  the  patient  himself  will  aid  the  therapeutic  measures 
by  self-control.  The  diagnosis  presents  no  difficulties  whenever  the 
physician  can  observe  a  patient  in  the  act  of  rumination  ;  regurgi- 
tation and  emesis  imply  the  spitting  out  of  food,  and  are  always 
associated  with  nausea  or  some  other  unpleasant  sensation. 

Treatment. — Medicinal  treatment  in  this  disease  is  of  little 
value.  The  state  of  the  secretions  should  be  carefully  determined, 
and  subacidity  or  achylia  corrected  by  the  administration  of  HCl, 
and  hyperchylia  by  the  use  of  calcined  magnesia  and  bicarbonate 
of  sodium.  Korner  is  enthusiastic  on  the  value  of  small  pieces  of 
ice  given  directly  after  meals.  The  stomach-tube  has  been  used 
for  the  lavage  and  artificial  feeding,  but  the  relief  has  been  only 
temporary.  The  physician  should,  however,  in  all  cases  insist  on 
slow  eating  and  careful  chewing ;  the  food  should  be  easily  digest- 


IXSUFFICIENXY    OR    INXONTIXEXCE    OF    THE    PYLORUS.  66/ 

ible  and  largely  composed  of  gruels  and  diet  of  a  soft  consistency. 
The  patient  should  always  take  his  meals  in  the  presence  of  persons 
for  whom  he  has  considerable  respect,  and  who  understand  to 
oppose  the  morbid  habit  with  kindness  and  yet  with  severity.  The 
success  of  the  treatment  will  depend  upon  the  will-power  of  the 
patient  himself  Whenever  the  patient  feels  a  desire  to  ruminate 
he  should  be  prompted  to  resist  the  temptation  with  all  the  self- 
control  at  his  command.  He  should  be  guarded  against  using 
the  contraction  of  the  abdominal  muscles  to  assist  the  act.  Pons- 
gen,  Boas,  and  Einhorn  report  permanent  cures  resulting  from  such 
persistent  autosuppression.  A  trial  might  be  made  with  the  intra- 
gastric use  of  the  faradic  and  galvanic  current.  Hydropathic 
methods  are  sometimes  useful.  In  one  case  observed  by  the  author, 
in  which  every  meal  was  persistently  ruminated,  we  carried  out 
rectal  alimentation  for  twelve  days,  not  allowing  anything  to  enter 
the  stomach  during  this  time.  Since  then  four  months  have  elapsed 
and  rumination  has  not  thus  far  returned.  We  hesitate  in  attribut- 
ing this  recovery  to  the  rectal  alimentation,  although,  of  course,  it 
was  impossible  for  the  patient  to  regurgitate  and  ruminate  when  no 
food  was  contained  in  the  stomach.  However,  the  psychic  effect 
of  hospital  treatment,  the  entirely  new  surroundings,  and  attendance 
by  intelligent  nurses,  the  constant  rest  in  bed,  may  have  contributed 
as  much  as  the  rectal  feeding  toward  the  recover}'.  In  another 
case  the  author  cured  the  patient  by  giving  ten  grains  of  quinin 
after  each  meal.  The  good  result  is  not  attributed  to  the  anti- 
malarial effect,  but  rather  to  the  fact  that  the  quinin  rendered  the 
food  so  disgustingly  bitter  that  the  patient  suppressed  the  regurgi- 
tation. Rossier  claims  to  have  cured  one  case  by  muriate  of  mor- 
phin,  and  another  by  large  doses  of  opium.  In  our  experience 
these  remedies  have  been  useless. 

INSUFFICIENCY  OR  INCONTINENCE  OF  THE  PYLORUS. 
It  has  been  known  for  a  long  time  that  an  insufficienc}'  or  incon- 
tinence of  the  pylorus  may  be  caused  by  organic  diseases  of  the 
stomach  and  intestines,  by  carcinoma  and  ulcer,  by  bringing  about 
a  partial  or  complete  obliteration  or  carcinomatous  infiltration  of 
the  annular  muscle,  so  that  the  latter  becomes  incapable  of  function- 
ing; or  it  maybe  caused  by  a  stenosis  of  the  duodenum  leading 
to  advanced  dilatation  of  the  initial  part  of  the  same.  Attention 
was    first   called   by    Ebstein    to    those    interesting,  though    very 


668  NEUROSES    OF    THE    STOMACH. 

rare,  cases  of  insufficiency,  which  appear,  in  the  absence  of  ana- 
tomical changes,  genuine  neuroses — paralysis  of  the  motor  nerves 
of  the  annular  muscle.  It  had  been  previously  observed  by 
Ebstein  as  a  concomitant  phenomenon  of  myelitis  due  to  compres- 
sion, and  also  in  hysteria  and  gout ;  but  it  may,  perhaps,  occur 
also  as  an  idiopathic  malad}-.  If  the  muscular  insufficiency  is  con- 
fined to  the  pylorus,  then  the  foods  and  liquids,  according  to  the 
degree  of  the  insufficiency,  either  remain  a  very  much  shorter 
time  than  usual  in  the  stomach,  or  enter  the  intestines  immediately 
after  their  ingestion.  The  nutriments  then  are  not  at  all  digested 
in  the  stomach,  or  only  to  a  slight  degree,  so  that  the  whole,  or 
almost  the  whole,  burden  of  digestion  falls  upon  the  intestine. 
Since,  however,  repeated  experiments  upon  human  beings  and 
animals  have  proven  that  the  intestine,  in  normal  conditions,  may 
entirely  make  up  for  the  lack  of  digestion  in  the  stomach — and 
the  experience  gained  from  the  treatment  of  persons  that  have 
undergone  a  resection  of  the  pylorus  confirms  this,  therefore,  even 
with  protracted  duration  of  the  p}-loric  insufficiency,  disturbances 
of  nutrition  generally  fail  to  appear,  especially  when  an  easily 
digestible  diet  is  prescribed,  suitable  to  the  malady,  and  provided 
that  the  intestinal  functions  are  normal. 

The  symptoms  of  pyloric  insufficiency  are,  in  brief,  the  following, 
viz. :  If  frequent  vomiting  and  belching  existed,  these  suddenly  cease 
after  the  setting  in  of  the  insufficiency.  If  rather  large  particles  of 
food  get  into  the  intestine,  which  mechanically  irritate  its  mucous 
membrane  more  than  usual,  then  the  increased  peristalsis  may  cause 
diarrhea.  This  may  also  be  brought  about  by  very  cold  or  very 
hot  foods  or  drinks,  which  are  gradually  warmed  or  cooled  by  the 
stomach,  as  the  case  may  be,  before  their  entrance  into  the  intes- 
tine, when  the  closure  of  the  pylorus  is  normal.  If  a  quantity  of  air 
was  swallowed  with  the  foods,  or  if  drinks  rich  in  carbonic  acid  have 
been  imbibed  (beer,  seltzer  water,  champagne),  a  very  acute  tym- 
panites of  the  intestine  may  develop  from  the  escape  of  air  or  car- 
bonic acid  gas. 

According  to  Ebstein,  one  can  not  succeed  in  distending  the 
stomach  with  the  artificial  production  of  carbonic  acid  gas  in  the 
organ  by  acid.  tart,  and  sod.  bicarb.  ;  but  Ewald,  Boas,  and  other 
authors  justly  contend  that  this  evidence  is  not  conclusive;  since, 
even  when  the  musculature  of  the  pylorus  functions  in  a  normal 
manner,  every   attempt   at   distending   the   stomach   by  means   of 


DIAGNOSIS    OF    PYLORIC    INSUFFICIENCY.  669 

gases  may  remain  unsuccessful,  because  the  amount  of  the  gases 
formed  is  too  small.  Further,  with  an  empty  stomach  the  pylorus 
(Kussmaul)  is  normally  so  relaxed  that  a  portion  of  the  carbonic 
acid  gas  may  easily  pass  over  into  the  intestine,  without  the  pres- 
ence of  any  real  insufficiency.  This  source  of  error  may,  however, 
be  removed  by  letting  the  patient  eat  a  test-breakfast  before  the 
distention  of  the  stomach  (Fleischer),  since  then,  under  normal  cir- 
cumstances, the  closure  of  the  pylorus  becomes  so  firm  that  the 
carbonic  acid  gas  set  free  can  not  at  once  escape  into  the  intestine; 
or  if,  instead  of  CO2,  air  is  forced  into  the  stomach  by  means  of  a 
tube  and  a  pump,  increasing  the  supply  according  to  necessity.  If 
the  air  passes  quickly  into  the  intestine  the  inflated  ascending  colon 
appears  as  a  thick  swelling  on  the  right  side  of  the  abdomen.  For 
a  proof  of  the  purely  nervous  origin  of  insufficiency  it  is  necessary 
to  exclude  the  above-mentioned  diseases  of  the  stomach  and  intes- 
tine, and  such  organic  diseases  of  the  stomach  as  chronic  gastritis, 
which  probably  bring  about  a  serous  infiltration  of  the  annular 
muscle,  and  may  lead  to  a  temporary  insufficiency  (Eichhorst, 
Boas).  If  the  insufficiency  be  due  to  a  stenosis  of  the  duodenum, 
the  stomach  may  very  well  be  distended  by  CO2,  or  air,  in  spite  of 
insufficiency.  If,  after  finding  out  the  lower  limits  of  the  stomach, 
quantities  of  water  are  introduced  through  the  tube,  and  no  dullness 
appears  in  the  lower  parts,  while  gurgling  noises,  before  lacking, 
now  become  audible  in  the  intestine,  and  if  the  intestinal  loops, 
just  before  this,  gave  a  tympanitic  resonance,  and  after  the  intro- 
duction of  water  exhibit  a  muffled  sound,  insufficiency  is  to  be 
inferred.  After  the  introduction  of  one  grain  of  salol,  or  o.i  gr. 
of  iodoform,  with  the  test-breakfast,  salicyluric  acid  can  be  shown 
in  the  urine  after  taking  the  former,  and  iodin  in  the  saliva  after 
taking  iodoform,  much  sooner  than  with  continence  of  the  pylorus, 
as  these  chemicals  enter  more  quickly  into  the  intestine,  and  on 
account  of  the  neutralization  of  the  hydrochloric  acid  by  the  alka- 
line intestinal  juice,  they  are  immediately  converted  into  soluble 
compounds  which  may  be  absorbed.     (See  pp.  73,  74.) 

Insufficiency  of  the  pylorus  may  be  recognized  by  the  author's 
method  of  intubating  the  duodenum  [Archiv  f.  Verdmiungskrank- 
heit.,  Bd.  11, S.  85),  and  by  the  spiral  revolving  sound  of  F.  Kuhn,  of 
Giessen,  and  of  F.  B.  Turck,  both  of  which  may  be  used  forsounding 
the  pylorus.  This  operation  was  first  performed  by  the  author  and 
also  by  Dr.  Turck,  and  Kuhn's  claims  of  priority  of  sounding  the  py- 
44 


6/0  NEUROSES    OF    THE    STOMACH. 

lorus  are  unfounded.  The  interesting  observation  of  a  case  of  insuffi- 
ciency, reported  by  Schiitz,  in  which  it  was  possible  to  distend  the 
stomach  by  means  of  CO2  but  not  by  air,  so  that  by  the  increased 
irritation  of  the  mucous  membrane  of  the  pylorus  by  the  carbonic 
acid  gas  a  contraction  of  the  annular  muscle  was  brought  about, 
but  with  the  forcing  in  of  air  the  stomach  did  not  become  distended, 
points  to  the  fact  that  different  degrees  of  insufficiency  occur.  If, 
as  easily  happens  in  a  case  of  pyloric  insufficiency,  some  of  the 
contents  of  the  intestine  go  back  into  the  stomach  causing  dys- 
peptic complaints  by  the  irritation  of  the  mucous  membrane  and 
neutralization  of  the  HCl,  this  can  be  recognized  by  testing  for 
bile  (p.  121). 

Therapeutics. — If  symptoms  of  irritation  of  the  intestine — 
namely,  diarrhea — are  absent,  only  dietetic  treatment  is  necessary. 
In  order  to  relieve  the  intestine  of  its  excessively  burdensome  task, 
we  must  prescribe  easily  digestible,  well-prepared  foods,  which 
are  to  be  carefully  masticated,  and  are  not  to  be  taken  too  hot  or 
too  cold. 

If,  on  the  other  hand,  complaints  such  as  diarrhea  appear,  we 
must  attempt,  in  addition  to  the  treatment  of  the  causal  disease,  to 
get  rid  of  the  insufficiency  by  means  of  massage,  internal  and  ex- 
ternal galvanization  and  faradization  applied  directl}^  to  the  pylorus 
by  the  author's  method  (p.  55),  douches,  and  eventually  also  by 
giving  strychnin,  gr.  -^^,  t.  i.  d.  If  flatulence  and  constipation 
arise  on  account  of  the  neutralization  of  hydrochloric  acid  which, 
as  is  well  known,  has  a  stimulating  effect  upon  the  peristalsis  of  the 
intestine,  and,  further,  acts  as  an  antiseptic,  then  the  massage,  as 
well  as  the  galvanization,  is  to  be  applied  also  to  the  intestine,  and 
dilute  HCl  should  be  administered  in  doses  of  30  drops  largely 
diluted  and  taken  after  meals  through  a  tube.  In  all  other  indica- 
tions the  treatment  must  be  directed  to  the  cause. 

ATONY  OF  THE   STOMACH   (Myasthenia   Gastrica,  Mechanical 
Insufficiency  of  the  Stomach). 

In  the  consideration  of  dilatation  of  the  stomach,  we  have  fully 
quoted  the  classifications  of  Riegel,  Schreiber,  Boas,  Naunyn,  and 
Rosenbach.  By  simple  atony  we  mean  that  combination  of  symp- 
toms in  which  there  exists  a  disproportion  between  the  peristaltic 
work  the  stomach  has  to  perform  and  its  real  expelling  muscular 
force.     Objectively,  the   disease   makes   itself  known    by  the  fact 


ATONY   OF    THE    STOMACH.  6/ 1 

that  the  ingesta  is  retained  in  the  stomach  beyond  the  normal 
time,  but  although  the  muscular  action  of  the  organ  is  weakened, 
the  food  is  eventually  expelled  into  the  duodenum.  By  this  it  is 
distinguished  from  the  mechanical  insufficiency  of  the  second  degree, 
the  pronounced  dilatation,  in  which  the  food  is  permanently  retained 
in  the  stomach,  and  onl}^  exceptionally  reaches  the  bowels.  Every 
relaxation  of  the  muscular  wall  that  is  not  due  to  any  pyloric  or 
other  mechanical  obstruction  may  be  justly  designated  as  an  atony. 
In  simple  atony  the  stomach  is  not  considerably  enlarged  in  the 
empty  state,  but  only  becomes  so  with  increasing  burdening  of  the 
ingesta,  but  in  atonic  dilatation  the  diseased  organ  remains  in  a 
dilated  state  even  after  it  is  empty,  (i)  This  disease  may  occur 
as  a  typical,  primary,  idiopathic  neurosis,  as  a  consequence  of  per- 
sistent overloading  the  stomach  with  indigestible  food,  particularly 
with  liquids.  It  may  appear  very  suddenly  as  a  transient  affection, 
under  the  influence  of  violent  emotional  disturbances, — fright,  anger, 
grief,  etc.,  occurring  in  this  way  principally  in  neurasthenic  persons. 
It  is  probable  that  gastric  myasthenia  may  be  inherited,  and  may  be 
transmitted  through  several  generations.  It  is  generally  referred  to 
as  the  so-called  "  weak  stomach  "  in  some  families.  The  abuse  of 
alcoholic  liquors,  particularly  of  beer,  and  even  of  coffee  and  soups, 
has  been  assigned  as  a  cause.  (2)  Myasthenia  occasionally  appears 
as  a  reflex  neurosis  evolved  from  other  diseased  organs;  for  instance, 
diseases  of  the  liver,  bile  passages,  peritoneum,  intestines,  kidney, 
and  sexual  apparatus.  (3)  It  occurs  as  a  secondary  neurosis, 
constituting  part  of  the  symptoms  of  hysteria,  neurasthenia, 
gastrospasm,  cardiospasm,  and  pylorospasm.  It  has  been  observed 
as  a  complication  of  gastroptosis,  nervous  dyspepsia,  of  ulcer,  and 
chronic  gastritis.  There  are  a  number  of  intestinal  affections 
which  may  be  complicated  or  even  cause  atony.  These  are 
stenosis  in  the  inferior  horizontal  portion  of  the  duodenum,  or 
stenosis  of  the  jejunum,  enteroptosis,  and  stenosis  of  the  colon; 
passive  congestions  and  enlargements  of  the  liver,  cholelithiasis, 
are  definitely  known  to  be  etiological  factors.  Critically  speaking, 
we  designate  only  such  cases  gastric  aton}-  in  which  the  organ  re- 
tains its  normal  size  when  it  is  empty.  As  soon  as  the  stomach 
remains  permanently  enlarged,  even  when  it  is  empty,  it  is  more 
logically  classed  with  the  motor  insufficiency  of  the  second  degree, 
as  atonic  dilatation.  As  we  have  seen  in  the  section  referred  to, 
Riegel  makes  a  separate  class  for  stenotic  dilatation. 


672  NEUROSES    OF    THE   STOMACH. 

The  final  cause  of  simple  atony,  or  myasthenia,  is  malnutrition, 
overstretching  of  the  muscles  and  motor  nerves  of  the  stomach,  or 
an  early  and  progressed  exhaustion  after  undue  and  improper  ex- 
ertions. Occasionally  unknown  neurotrophic  influences  may  be  re- 
sponsible for  the  origin  of  atony.  As  secretion  and  absorption  depend 
more  or  less  upon  energetic  contraction  of  the  gastric  muscularis, 
they  are  in  most  cases  interferred  with  in  the  absence  of  effective 
muscular  tonicity.  The  gastric  contents  do  not  diminish  in  quantity 
as  rapidly  as  they  should,  and  in  consequence  of  this  the  gastric  wall 
is  excessively  expanded  by  the  prolonged  weight  of  food.  If  fermen- 
tation of  the  ingesta  occurs  with  abundant  formation  of  gases,  the  ex- 
pansion will  be  still  greater.  The  gaseous  distention  may  secondarily 
produce  spasm  of  the  pylorus  and  cardia,  thus  adding  another  etio- 
logical factor  to  the  causation.  If  the  atony  is  very  progressed  and 
has  persisted  for  a  long  time,  it  may  develop  into  an  irreparable 
dilatation,  particularly  if  dietetic  and  hygienic  regulations  are  dis- 
regarded. We  have  observed  a  number  of  cases  of  this  kind,  in 
which  permanent  dilatation  was  developed  when  long-standing 
gastric  distress  was  left  unheeded.  Myasthenia — by  diagnostic 
methods  for  judging  the  motility — may  be  found  to  be  very  pro- 
nounced, and  still  remain  latent  and  unnoticed  even  by  the  patient 
for  a  long  time. 

The  following  is  an  example  of  this  class  of  cases.  Miss  S., 
aged  twenty-two,  a  well-built  and  apparently  healthy  girl,  moving  in 
the  best  circles  of  social  life,  complains  of  only  one  symptom,  that 
is  a  severe  headache,  occurring  two  or  three  times  of  every  week, 
and  lasting  for  twenty-four  hours.  On  being  questioned  about  her 
stomach  she  asserts  that  her  digestion  is  good,  appetite  excellent^ 
and  bowels  regular.  She  eats  all  kinds  of  food,  apparently  without 
distress.  On  passing  the  tube  in  the  morning,  on  an  empty  stom- 
ach, 200  c.c.  of  a  slightly  yellowish  mucous  liquid  was  obtained  which 
shows  free  HCl  by  Congo  paper.  The  next  day  she  was  directed 
to  take  the  double  test-meal  (described  on  p.  11 1).  One  hour  after 
the  second  meal  the  contents  were  drawn,  and  rice  and  egg  of  the 
early  breakfast,  which  was  taken  six  and  a  half  hours  before, 
were  still  present  in  her  stomach,  together  with  a  considerable 
amount  of  mucus.  Total  acidity,  60 ;  free  HCl,  20.  Subsequently 
the  same  state  of  affairs  was  found  after  other  test-meals.  The 
striking  feature  of  this  case  is  that,  although  there  is  a  pronounced 
gastric  atony,  the  patient  is  not  at  all  conscious  of  it,  and  regularly 


DIFFERENTIAL    DIAGNOSIS    OF    ATONY.  673 

expresses  surprise  when  she  recognizes  food  in  the  lavage  that  has 
been  taken  eight  to  twelve  hours  before.  It  is  very  probable  that  such 
cases  as  this  one  would  develop  unmistakable  symptoms  of  myas- 
thenia in  a  very  short  time  if  left  untreated.  Superacidity  and  super- 
secretion  may  cause  cardiospasm  and  pylorospasm,  and  subsequently 
gastric  atony,  by  the  irritation  of  the  muscular  structures  at  the  orifices 
caused  by  the  intense  acidity.  But,  reversely,  gastric  atony  may 
cause  superacidity  and  supersecretion  by  the  fact  that  the  ingesta 
are  retained  in  the  stomach  for  an  unduly  long  period,  and  thereby 
excite  the  gastric  glands  to  stronger  functioning.  Stiller  and  Boas 
assert  that  gastric  atony  rarely  develops  into  permanent  gastric  dila- 
tation. The  subjective  symptoms  of  gastric  atony  are  very  similar  to 
those  of  gastritis  and  insipient  dilatation.  The  patients  complain  of 
pressure  and  pain  in  the  head,  the  feeling  of  pressure  and  disten- 
tion in  the  stomach,  a  premature  sensation  of  fullness  during  eating 
by  which  the  appetite  becomes  appeased  very  rapidly,  very  frequent 
eructation,  and  persistent  constipation.  The  feeling  of  pressure  is 
intimately  associated  with  the  ingestion  of  food.  When  the  stom- 
ach is  empty,  the  patient  feels  quite  well.  The  headache  is  very 
frequently  observed,  together  with  the  so-called  stomach  vertigo. 
We  can  agree  with  Boas  that  this  so-called  gastric  vertigo 
(Trousseau,  Gazette  des  Hopitaiix,  1862)  is  much  more  frequently 
found  in  atony  and  dilatation  than  in  any  other  gastric  disease. 
The  feeling  of  pressure  and  distention  may  persist  as  long  as  there 
is  food  in  the  stomach:  in  recent  cases,  about  one  hour;  in  ad- 
vanced cases,  it  continues  from  one  meal  to  the  other.  One  of  the 
most  frequent  symptoms  is  eructation  of  air,  which  generally  has 
the  taste  of  the  food  that  has  been  last  taken.  We  have  noticed 
that  the  most  annoying  sensations  of  pressure  in  the  advanced  cases 
are  felt  after  breakfast,  at  a  time  when  one  would  presume  that  they 
should  be  absent,  since  the  stomach  should  have  been  rested  dur- 
ing the  night.  The  duration  of  the  time  after  meal  during  which 
the  eructations  continue  is  generally  a  good  indication  of  the  ex- 
tent and  degree  of  the  myasthenia.  In  some  cases,  however,  we  may 
be  confronted  with  typical  neurotic  regurgitation  and  eructation, 
that  has  existed  before  the  atony  developed,  and  then  this  indica- 
tion is  invalid.  If  there  is  hyperacidity,  the  atony  may  be  asso- 
ciated with  attacks  of  vomiting,  and  pyrosis  is  generally  present. 
The  constipation  is  undoubtedly  an  expression  of  the  general  atony 
of  the  entire  gastro-intestinal  tract. 


674  NEUROSES    OF    THE    STOMACH. 

Objective  Symptoms. — The  most  important  distinguishing 
sign  between  simple  atony  and  dilatation  consists  in  the  fact 
that  the  stomach,  in  the  former,  should  be  empty  in  the  morn- 
ing, when  nothing  has  been  taken  since  the  previous  supper? 
in  other  words,  the  jejune  stomach  of  atony  contains  no  food 
particles,  while  the  stomach  in  a  state  of  dilatation  does  con- 
tain them.  The  splashing  sound  in  the  epigastric  region  is 
absent  in  the  morning  with  simple  atony,  but  it  is  present  in 
dilatation.  The  size  and  location  of  the  stomach  vary  physiologi- 
cally. A  myasthenic  stomach  yields  and  distends  with  greater 
readiness  when  it  is  filled  with  water  or  air  than  a  normal  stomach. 
Boas  asserts  that  even  an  atonic  stomach  may  react  more  normally 
to  the  distending  force  of  water  and  air  in  cases  in  which  the  super- 
imposed layers  are  swelled  and  much  thickened  by  inflammatory 
infiltration.  The  methods  of  investigation  and  diagnosis  which  we 
have  found  useful  are,  in  addition  to  inspection,  palpation,  percus- 
sion, and  auscultation,  the  distention  of  the  stomach  by  air  or 
carbon  dioxid  gas,  the  Hemmeter  intragastric  stomach-shaped  bag 
and  the  gastrodiaphane.  Very  frequently  the  contour  of  the  greater 
curvature  maybe  recognized  on  the  outside  of  the  abdomen.  Pal- 
pation may,  in  some  cases,  instruct  us  concerning  the  limits  of  the 
organ,  and  enable  us  to  separate  it  from  adjacent  organs.  The  so- 
called  splashing  sound  may  be  elicited  by  permitting  the  patient  to 
drink  a  glass  of  water,  and  then,  placing  the  palm  of  the  left  hand 
firmly  over  the  right  hypochondriac  region,  and  by  gently  tapping 
the  epigastrium  with  the  right  hand,  the  sound  is  generally  very 
evident  if  atony  is  present.  In  most  cases  of  gastric  atony  a  splash- 
ing sound  can  be  heard  with  binaural  stethoscope  on  shaking  the 
stomach  from  the  outside.  Dehio  has  given  a  very  expedient 
method  for  judging  the  elasticity  of  the  gastric  walls  by  means  of 
gradually  increasing  quantities  of  water;  at  first  ^^  of  a  liter 
is  taken,  and  the  location  of  the  greater  curvature  determined ; 
then,  in  short  intervals,  y^  oi  di  liter  is  taken  at  three  successive 
periods,  and  after  each  i^  of  a  liter  increment  the  further  descent  of 
the  greater  curvature  is  determined  by  palpation  and  percussion. 
A  healthy  stomach  will  not  reach  the  line  of  the  umbilicus  under 
these  conditions,  while  an  atonic  stomach  may  have  trans- 
gressed far  beyond  it.  Auscultation  elicits  sounds  only  when  the 
stomach  contains  liquids  or  shortly  after  they  are  ingested.  It  is 
best  to   use  the  binaural  stethoscope  in  these  cases,  as  then  both 


CAPACITY  AND  LOCATION  OF  THE  STOMACH.         675 

hands  are  free  to  palpate  and  move  the  stomach  to  obtain  the 
percussion  sound.  Boas  holds  that  we  have  no  reliable  method  to 
test  the  gastric  elasticity  and  tonicity  [loc.  cit.,  p.  yG).  We  con- 
sider that  our  method  of  recording  the  gastric  peristalsis  on  the 
kymograph,  as  described  in  the  first  part  of  this  book,  is  also  an. 
excellent  method  for  investigating  the  gastric  tonicity,  for,  as  our 
stomach-shaped  intragastric  bag  on  being  distended  gradually 
fills  out  the  lumen  of  the  stomach  exactly,  the  indications  of 
pressure  which  are  obtained  on  the  kymograph  are  reliable  repre- 
sentations of  the  tonicity.  Moreover,  we  have  experimented  with 
an  electrodiaphane  contained  within  our  stomach  bag,  so  that 
when  the  bag  was  distended  in  a  dark  room  the  gradual  descent  of 
the  greater  curvature  could  very  plainly  be  seen.  By  reference  to 
the  description  of  the  apparatus  on  pages  y6  to  78,  it  will  become 
evident  that  we  can  easily  determine  the  amount  of  air  or  water  with 
which  the  bag  is  distended  within  the  stomach;  so  with  this  method, 
which  in  a  modified  form  was  also  used  independently,  after  our 
first  publication  by  Professor  Moritz,  of  Munich,  for  studying  the 
gastric  motility,  we  may  determine  also  the  elasticity  and  tonicity  of 
the  stomach. 

Percussion. — In  percussion  of  the  stomach,  we  must  attempt  to 
define  its  four  limits,  viz. :  the  upper,  lower,  right,  and  left  limit. 
The  lower  limit  may,  on  percussion,  be  confounded  with  the  trans- 
verse colon  if  the  latter  still  be  in  its  normal  position.  The  way  out 
of  this  difficulty  is  to  fill  the  transverse  colon  with  water,  which 
gives  a  dull  percussion  note  through  the  abdominal  wall,  while  the 
stomach  may  be  distended  with  air  or  gas,  giving  a  clear  tympanitic 
sound.  When  both  the  stomach  and  the  colon  are  filled  with  gas  or 
with  solid  material  simultaneously,  it  is  almost  impossible  to  dis- 
tinguish between  the  two  by  percussion.  It  is  best  to  evacuate  the 
colon  and  fill  the  stomach  with  water,  or  vice  versa  to  evacuate 
the  stomach  and  fill  the  colon  with  water.  In  our  clinic  we  use  the 
rubber  stomach-shaped  intragastric  bag  methodically,  and  when  it 
is  distended  there  is  no  difficulty  at  all  to  percuss  and  palpate  the 
stomach.  The  determination  of  the  upper  border  of  the  stomach 
is,  in  our  experience,  no  easy  matter,  since  there  are  no  very  striking 
differences  in  the  percussion  note  of  the  lower  edge  of  the  left 
lung  and  the  highest  portion  of  the  gastric  fundus  which  is  nor- 
mally covered  over  anteriorly  by  the  lung  in  inspiration.  The  upper 
border  may  be  best  determined  by  filling   the  stomach  with  water 


6/6  NEUROSES    OF   THE    STOMACH. 

and  then  percussing  over  the  left  lung  along  the  parasternal  line  from 
above  downward.  Pacanowski  {Dciitscli.  Arch.  f.  klin.  Medizin, 
Bd.  XL,  S.  342)  gives  the  following  determinations  of  the  upper 
limit  of  the  stomach.  In  the  left  parasternal  line  it  is  at  the  lower 
edge  of  the  fifth  rib  or  in  the  fifth  intercostal  space.  In  the  left 
mamillary  line  the  limit  is  in  the  fifth  intercostal  space  extending 
to  the  sixth  rib,  or  into  the  seventh  rib.  In  the  anterior  left 
axillary  line  the  upper  limit  is  at  the  lower  edge  of  the  seventh  or 
eighth  rib,  rarely  under  the  eighth  rib.  The  determination  of  the 
left  and  right  gastric  limits  seems  most  hyperthetical  to  us  and  not 
of  diagnostic  value,  because  here  we  may  confound  the  percussion 
notes  of  organs  superimposed  upon  the  stomach. 

In  our  experience,  a  clear  conception  of  the  size  and  location  of 
a  normal  stomach  can  only  be  obtained  when  it  is  distended  by 
gas,  air,  or  water.  Naturally,  this  can  not  be  done  if  there  is  any 
suspicion  of  recent  ulcer,  cancer,  or  perigastritis.  We  have 
already  spoken  of  the  value  of  the  electrodiaphane  in  ascertain- 
ing the  size  and  location  of  the  stomach,  and,  notwithstanding 
numerous  objections,  consider  the  method  practical.  According 
to  Kuttner  and  Jacobsohn  {Berlin  klin.  Wochefischr.,  1893,  No.  39), 
a  prolapsus  of  the  stomach  may  be  distinguished  from  a  dilated 
stomach  by  the  fact  that  the  dilated  organ  changes  its  position  with 
inspiration  and  expiration  because  it  is  in  juxtaposition  to  the 
diaphragm,  whereas  a  gastroptosis  does  not  change  its  position 
during  respiration.  C.  A.  Meltzing  (y^/r/^./.  VerdmmngskrankJieiten, 
Bd.  II,  S.  436)  has  confirmed  the  observations  of  Schwartz  that 
gastrodiaphany  has  an  undoubted  diagnostic  value.  It  is  impor- 
tant to  emphasize  this  fact,  since  the  method  has  been  criticized  by 
Renvers,  Kuttner,  and  Jacobsohn,  who  have  asserted  that  intestinal 
loops  filled  with  gas,  when  adjacent  to  the  stomach,  will  also 
become  translucent  or  luminous  when  the  light  is  introduced  into 
the  stomach,  and  Langerhans  {Wiener  vied.  Blatter,  1895,  No.  45) 
denies  that  electric  transillumination  of  the  stomach  has  any  diag- 
nostic value  whatever.  We  believe  that  the  method  is  not  only 
practical,  but  very  useful,  and  that  the  objections  of  its  adversaries 
have  been  squarely  met  and  disproved  by  the  report  of  Aleltzing 
(see  pp.  102  to  104). 

After  all,  the  most  convenient  method  of  determining  gastric 
atony,  and  that  which  is  available  for  every  practitioner,  is  by  means 
of  the  double  test-meal  used  in  our  clinics  (see  pp.  in  and  112). 


PROGNOSIS    AND    DIAGNOSIS    OF    ATONY.  67/ 

According  to  Boas'  suggestion,  a  full  meal  is  preferably  given  in  the 
evening,  when  a  healthy  stomach  will  show  no  demonstrable  signs 
of  food  particles  the  next  morning.  It  should  not  be  forgotten,  in  this 
connection,  that  even  healthy  stomachs  may  contain  mucus,  gastric 
juice,  and  bile  in  the  morning  before  food  is  taken.  The  chemical 
analysis  of  the  stomach  contents  in  gastric  atony  yields  no  results 
useful  for  diagnosis,  because  the  state  of  the  secretion  varies  con- 
siderably according  to  the  degree  of  the  mechanical  insufficiency. 
In  the  primary  stages  of  gastric  atony  superacidity  is,  as  a  rule, 
present;  at  other  times  the  secretions  may  be  normal,  and,  in  the 
latter  stage,  we  may  have  subacidity  or  even  achylia.  The  drawn 
stomach  contents  of  atony,  on  settling  in  a  glass  vessel,  do  not 
show  the  three  characteristic  layers  of  solid,  liquid,  and  froth  which 
are  usually  found  in  the  drawn  stomach  contents  of  dilatation.  We 
have  never  observed  processes  of  fermentation  in  simple  atony. 
The  secretion  of  pepsin  and  rennin  is  generally  found  to  be  propor- 
tionate to  the  secretion  of  HCl.  Thirst  is  normal,  and  the  amount 
of  urine  passed  is  not  reduced.  Disturbances  in  nutrition  may 
gradually  develop  if  the  diet  is  inappropriate  or  if  the  patient  refuse 
to  eat  sufficiently  for  fear  of  causing  gastric  distress. 

The  course  of  gastric  atony  is  a  chronic  one,  and  the  symptoms 
are  subject  to  many  deviations.  Stiller  and  Boas  hold  that  gastric 
atony  comparatively  rarely  develops  into  dilatation.  Notwith- 
standing this,  the  disease  generally  produces  considerable  systemic 
weakness.  A  variety  of  nervous  disturbances  accompany  the 
malady. 

Prognosis. — In  recent  cases,  the  prognosis  is  favorable,  pro- 
vided that  they  are  systematically  treated  and  the  fundamental 
causatives  of  the  disease  can  be  removed ;  but  in  pronounced 
atony,  and  that  of  long  standing,  complete  recovery  is  rare. 

Diagnosis. — Gastric  atony  and  myasthenia  may  be  confounded 
with  chronic  gastritis,  nervous  dyspepsia,  dilatation,  and  megalo- 
gastria.  In  chronic  gastritis  the  stomach  is  not  enlarged,  as  a  rule, 
since  the  motility  is  good;  excess  of  mucus  is  common  in  gastritis 
and  rare  in  atony;  as  atony  may  predispose  to  gastritis,  the  two 
affections  may  sometimes  exist  side  by  side.  Nervous  dyspepsia 
is  characterized  by  a  great  deviation  and  uncertainty  in  the  symp- 
toms ;  even  the  motility  may  be  at  times  seemingly  much  affected, 
but  at  others,  if  the  case  be  strictly  watched,  the  motility  will  be 
found  to  be  perfect.  In  nervous  dyspepsia  there  are  painful  points  in 


678  NEUROSES    OF    THE    STOMACH. 

the  district  supplied  by  the  great  abdominal  S}'mpathetic  plexuses 
— the  celiac,  solar,  and  hypogastric.  The  painful  spots  are  rare  in 
simple  atony.  Nervous  dyspepsia  and  atony  may  exist  simulta- 
neously, and  one  may  cause  the  other;  in  such  cases  it  will  be  diffi- 
cult to  determine  which  is  the  primary  disease.  The  differential 
diagnosis  between  dilatation  and  simple  atony  should  present  no 
difficulties  when  modern  methods  of  determining  the  size  and 
capacity  and  motility  of  the  stomach  are  used  (pp.  97  to  104)  ; 
neither  should  there  be  any  difficulty  in  distinguishing  atony  from 
megalogastria,  since  the  latter  is  not  a  disease,  but  simply  a  condi- 
tion of  big  stomach,  which  performs  its  functions  normally. 

Treatment. — The  most  important  part  of  the  management  of 
gastric  atony  is  prophylaxis,  which  includes  the  avoidances  of  all 
known  causes  of  the  affection.  Defective  teeth,  irregular  mode 
of  life,  hasty  eating,  and  abnormal  burdening  of  the  stomach  with 
food  and  drink,  constipation,  as  well  as  the  frequent  abuse  of 
purgatives.  Even  where  the  distinct  cause  of  the  malady  is  not 
known,  one  will  do  best  to  prevent  the  full  development  of  myas- 
thenia by  rational  dietetic  and  hygienic  treatment  before  functional 
disturbances  become  manifest.  We  have  already  remarked  that 
atony  may  be  inherited.  Whenever  this  is  noticed,  such  persons 
should  be  particularly  guarded  and  careful  in  the  selection  of 
their  diet.  There  are  a  number  of  constitutional  diseases  which, 
in  our  experience,  undoubtedly  predispose  to  this  state.  These 
are  tuberculosis,  syphilis,  anemia,  chlorosis,  and  cholelithiasis.  It 
is  present  also  after  exhaustive  hemorrhages,  and  is  particularly 
ominous  when  the  condition  occurs  after  hemorrhages  from  gastric 
ulcer. 

Typhoid  fever  has,  in  our  experience,  frequently  been  followed 
by  gastric  atony ;  the  same  is  true  of  infectious  diseases  generally, 
particularly  scarlet  fever,  malaria,  diphtheria,  and  influenza.  We 
have  also  noticed  gastric  atony  follow  a  number  of  operations  for 
abdominal  tumors,  and  particularly  ovarian  neoplasms.  It  is  very 
probable  that  the  relaxation  of  the  gastric  walls  is  here  largely  due 
to  mechanical  causes,  similar  to  that  which  occurs  after  very  fre- 
quent and  rapidly  consecutive  pregnancies.  In  all  of  these  instances 
the  abdominal  walls  do  not  regain  their  tonicity.  We  have  described 
this  condition  fully  in  the  section  on  Gastroptosis.  Prophylaxis 
consists  in  appropriate  hygienic  living,  much  sleep  (at  least  nine 
hours  in  the  twenty-four),  and  strengthening  of  the  abdominal  mus- 


TREATMENT    OF    ATONY.  679 

cles — the  latter  is  one  of  the  most  important  elements,  not  only  in 
prophylaxis,  but  also  in  the  treatment  of  atony.  The  training  of  the 
abdominal  muscles  should  be  carried  out  according  to  rules  laid 
down  in  Sandow's  text-book  on  physical  culture.  The  treatment 
proper  of  a  fully-developed  atony  must  have  regard  for  the  funda- 
mental cause.  For  instance,  in  syphilis  specific  treatment  will  be 
the  only  proper  course  to  pursue;  in  anemia  we  must  have  re- 
course to  preparations  of  iron  which  have  no  direct  deleterious 
effect  upon  the  mucosa.  Among  these  preparations  we  prefer  the 
iron  albuminates  and  peptonates,  also  ferratin  and  extract  of  bone- 
marrow.  With  pronounced  enteroptosis,  particularly  in  women, 
abdominal  gymnastics  can  not  be  effectively  carried  out,  on  account 
of  the  great  exhaustion  of  the  patient. 

In  some  cases  of  this  type  palliative  results  may  be  obtained  by 
abdominal  massage,  faradization  of  the  abdominal  muscles,  baths, 
and,  last  but  not  least,  a  well-fitting  abdominal  bandage.  In  a  few 
cases  it  will  not  be  possible  to  trace  any  cause  whatever,  though 
even  in  these  it  is  well  to  carefully  study  the  alimentary  tract  itself 
before  giving  up  the  hope  of  determining  the  etiology.  The  most 
important  factors  of  direct  treatment  are  :  (i)  diet,  (2)  hydriatic, 
(3)  electric  procedures,  (4)  massage,  and  (5)  medicines.  The  prin- 
ciple underlying  the  diet  in  gastric  atony  is  that  of  frequent  and 
very  small  meals,  which,  although  quite  nutritious  and  digestible, 
must  not  be  voluminous.  The  diet  should,  as  a  rule,  consists  of  fats, 
carbohydrates,  and  proteids,  mixed.  If  there  is  an  excess  of  HCl, 
there  is  no  objection  to  increasing  the  proteid  food,  but  in  doing 
so  it  is  well  to  watch  the  ratio  of  the  ethereal  to  the  combined 
sulphates,  and  the  indican  in  the  urine.  If  the  ratio  of  the  pre- 
formed to  the  combined  sulphates  is  very  high,  and  there  is  an 
excess  of  indigo  in  the  urine,  it  is,  in  our  experience,  worth  the  trial 
of  adding  more  fats  and  artificially  prepared  amylaceous  foods, 
such  as  dextrinized  flours,  etc.,  for  it  has  been  found  that  the  gen- 
eral symptoms,  as  well  as  the  aforementioned  indications  in  the 
urine  (in  rare  instances,  in  which  proteid  diet  does  not  agree 
in  hyperacidity),  will  improve  if  the  proteids  are  cut  down  and 
the  other  food  substances  increased.  Together  with  this  diet  in 
hyperacidity,  the  use  of  alkalies,  magnesia  usta,  sodium  bicarbonate, 
etc.,  and  of  ptyalin,  or  of  malt  or  taka  diastase,  is  unavoidable. 
The  diet  which  we  recommend  for  gastric  atony  is  the  following : 


680  NEUROSES    OF    THE    STOMACH. 

8  A.  M. — 250  gm.  of  bouillon,  oat  meal,  or  100  gm.  of  milk  and  100  gm.  of  tea 

or  coffee. 
10  A.  M. — One  soft-boiled  egg,  or  70  gm.  of  finely-scraped  tenderloin,  either 

raw  or  broiled,  and  20  gm.  of  toast. 
12  M. — A  broiled    sweetbread,  or  150   gm.  of  broiled  oysters,  or   little  neck 

clams,  or  100  gm.  of  finely-scraped  beef  slightly  fried  in  butter  ;  200  gm. 
of  potato  puree,  and  if  hyperacidity  is  present,  we  give  half  a  wine- 
glassful  of  some  reliable  malt  extract. 
3  p.  M. — 200  gm.  of  Mosquera's  beef  chocolate  (P.,  D.  &  Co.) 
6.30  p.  M. — 60  gm.  of  scraped  raw  ham,  or  the  same  amount  of  fried  perch  or 

carp;  50  gm.  of  toast,  and  30  gm.  of  butter. 
10  P.  M. — 100  gm.  of  some  approved  light  Moselle  wine. 

In  the  section  on  Dietetics  we  have  given  other  diet  lists  suitable  for 
this  affection  (pp.  226  and  228).  A  number  of  competent  authors 
consider  the  treatment  of  atony  and  a  chronic  dilatation  together  in 
the  same  chapter.  Personally,  we  draw  a  very  sharp  distinction 
between  these  two  affections  and  their  treatment.  The  therapy  of 
dilatation  is  considered  in  the  chapter  devoted  to  this  subject. 

The  total  quantity  of  liquids  should  be  limited  to  ij4  liters  a 
day.  This  includes  the  soups,  coffee,  tea,  milk,  alcoholic  beverages, 
and  water.  Alcohol,  except  in  the  quantities  suggested  in  the  diet 
list,  should  not  be  allowed.  Purgatives  and  narcotics  are  forbidden- 
If  the  thirst  is  intense,  which,  however,  is  rarely  the  case,  water  may 
be  introduced  by  enema.  When  milk  is  well  digested,  and  no 
idiosyncrasy  exists  against  it,  so-called  milk  cures  may  have  a  bene- 
ficial effect.  There  is  no  doubt  that  an  exclusive  milk  diet  insures 
rest  and  is  very  sparing  upon  the  stomach,  but  it  is  a  two-edged 
sword.  We  have  seen  cases  in  which  the  atony  undeniably 
became  aggravated  by  the  milk  diet.  The  diet  must  vary  also  with 
the  amount  of  HCl  secreted.  With  increased  secretion  of  HCl  the 
meats  may  be  permitted  to  prevail.  All  meats  should  be  run  through 
the  meat  chopper.  Eggs  in  all  forms  are  permissible  in  this  state. 
When  the  secretion  of  HCl  is  diminished,  we  permit  the  use  of  spin- 
ach, carrots,  beans,  cauliflower,  and  asparagus.  All  vegetables 
should  be  cooked  and  given  in  the  form  of  purees ;  among  these  are 
the  potato,  rice,  sago,  pea,  and  bean  puree.  The  use  of  beer  should 
be  forbidden  or  very  greatly  limited ;  we  do  not,  as  a  rule,  forbid 
small  doses  of  good  wine.  Where  good  wine  can  not  be  obtained, 
it  is  safest  not  to  prescribe  wine  of  a  doubtful  quality,  but  to  order 
dilute  whisky  or  brandy.     Constipation  should  be  met  with  proper 


MEDICINAL    TREATMENT    OF    ATONY.  68 1 

diet,  and  medicines  should  not  be  used  unless  they  are  positively 
unavoidable.  We  have  already  spoken  of  the  diet  best  suited  for 
constipation  (p.  236).  In  very  stubborn  and  protracted  cases 
glycerin  suppositories  and  water  injections  will  be  more  effective 
than  medicines  given  by  the  mouth.  (See  E.  A.  Ewald,  "  Ueber 
d.  habituelle  Obstipation  u.  ihre  Behandlung,"  1897.)  An  advantage 
is  gained  by  going  to  stool  at  a  definite  hour.  There  are  cases, 
however,  in  which  a  natural  stool  that  occurs  every  two  or  even 
every  three  days  spontaneously  is  much  better,  and  will  do  more 
toward  gradual  recovery  from  the  evil  of  constipation  than  a  stool 
produced  artificially  every  day.  Where  the  patient  insists  on  medi- 
cine, and  it  is  really  unavoidable,  cascara  sagrada  is  most  favored 
by  the  author.  (The  syrup  cascara,  "active,"  Clinton  Pharm. 
Company,  and  the  elixir  of  cascara  sagrada.  P.,  D.  &  Co.,  or  S.  & 
D.,  can  be  safely  recommended.)  Podophyllin  in  the  form  of  pills  is 
a  proper  medication.  The  following  formula  is  the  one  which  we 
favor  : 

R.     Podophyllin, 0,26         grs.  iv 

Ext.  belladonnas,  or  ext.  hyoscyarai,     ......  O.I  gr.  ij 

Strychnin  sulphate,      ^    ....  0.2  S^-  /i 

Glycyrrhizse,  q.  s. 

F.  pil.  No.  xii.  M. 

SiG. — One  pill  before  supper  and  one  at  bedtime.      Dose  increased  to  two  pills 
the  next  day  if  necessary. 

The  compound  extract  of  rhubarb  is  also  an  effective  combination  ; 
but  calomel,  aloes,  colocynth,  jalap,  and  scammony,  and  the  very 
concentratedpurgative  waters,  such  as  the  Hunyadi  Janos,  the  Rubi- 
nat-Condal,  and  Veronica,  must  be  strictly  avoided.  Boas,  in  con- 
trast to  other  authors,  states  that  lavage  is  not  only  unnecessary,  but 
harmful  in  simple  atony,  because  stagnation  does  not  occur  in  this 
disease  and  there  is  therefore  no  necessity  for  washing  out  the 
stomach.  We  use  lavage,  however,  not  to  combat  any  presumable 
stagnation,  but  as  a  sort  of  intragastric  hydropathic  massage.  For 
this  purpose  we  use  an  intragastric  douche  with  hot  and  cold  water 
alternating.  The  electrical  treatment  with  which  Einhorn  has 
achieved  remarkable  results  is  undeniably  a  valuable  means  of 
therapeusis  in  this  affection.  It  may  be  applied  externally  with 
large  felt-covered  plates  applied  to  the  abdomen  directly,  or  by 
the  intragastric  electrode.  We  usually  apply  the  current  fifteen 
minutes  and  repeat  it  daily  for  three  weeks.     Massage  should  be 


682  NEUROSES    OF   THE    STOMACH. 

applied,  not  only  to  the  stomach,  but  to  the  entire  abdomen.  The 
method  of  application  (concerning  abdominal  massage  see  Hoffa, 
"  Technik  d.  Massage,"  Stuttgart,  Enke,  1893,  also  Penzoldt 
and  Stintzing,  "  Handbuch,"  Bd.  iv,  S.  34-39)  is  described  on 
pages  290-299. 

Treatment  by  Medicines. — Perhaps  the  only  drug  which  one  may 
depend  on  for  improving  the  gastric  tonicity  is  strychnin.  When 
atony  is  accompanied  with  suppression  of  gastric  juice  and  inacidity, 
we  can  practically  associate  it  with  HCl  and  gentian  in  the  follow- 
ing manner : 

li .      Strychnin  sulphate, 0.02  gr.  y^ 

Dil.  hydrochloric  acid, 15-6  f^iv 

EHxir  of  gentian, q.  s 180.0  f^vj.         M. 

SiG. — One-half  of  an  ounce  in  two  ounces  of  water,  after  meals,  through  a  glass 
tube,  three  times  a  day. 

Where  there  is  excess  of  HCl  it  is  well  to  combine  the  strychnin 
in  the  following  manner : 

R .      Strychnin  sulphate, 0.02  gr.  j^ 

Bismuth  salicylate, 7.5  ^ij 

Sodium  bicarbonate, 11-25  3^'! 

Magnes.  ustse, 4.0  ^j 

Peppermint  water  enough  to  make 180. o  5'^j-         M. 

SiG. — A  tablespoonful  in  a  wineglassful  of  water  after  each  meal  t.  i.  d. 

Creosote  has  been  recommended  by  Klemperer  {Berlin,  klin. 
Wochenschr.,  1889,  No.  ii)  and  A.  Pick  (Fori.  lib.  Magen-  u. 
Darmkrankh.,  1 895),  but  Fleischer  has  found  that  the  motility  is 
still  more  reduced  under  creosote.  Ergotin,  which  is  recommended 
by  Leube,  is,  in  our  opinion,  a  doubtful  remedy  for  this  purpose. 
Ichthyol  has  been  claimed  by  Pick  to  benefit  atony,  particularly  when 
it  is  associated  with  fermentative  processes  in  the  bowel.  In  severe 
cases  of  gastric  atony  with  recurrent  gastric  distress,  we  have  had 
very  gratifying  results  by  rectal  feeding  for  from  six  to  eight  days, 
and  total  exclusion  of  food  from  the  stomach  ;  that  is,  we  treated  the 
atony  as  we  would  treat  a  severe  gastric  ulcer.  During  the  period 
of  rectal  feeding  the  patient  must  remain  in  bed. 

LITERATURE  ON  NERVOUS  DISEASES  OF  THE  STOMACH. 

1.  Sollier,  Revue  de  Me decine,  Aoiit,  1891. 

2.  Gull,  Lancet,  1868. 

3.  Mitchell,  Weir,  "Fat  and  Blood,"  Philadelphia,  1884. 

4.  Rosenheim,  Th.,  Berl.  klin.  Wochenschr.,  1890, 


BIBLIOGRAPHY    OF    GASTRIC    NEUROSES.  683 

5.  Kahler,  Prager  Zeiischrift  f.  Heilktinde,  Bd.  Ii. 

6.  Demange,  Revue  de  Medecifie,  1892. 

7.  Landouzy  et  Dejerine,  Societe  de  Biologie,  1884. 

8.  Oppenheim,  Berlin,  klin.  Wochenschr.,  1885. 

9.  Renvers,  Berl.  klin.  Wochenschr.,  1888,  No.  53. 

10.  Max  Einhorn,  "  A  Case  of  Dysphagia  with  Dilatation  of  the  Esophagus," 
Medical  Record,  1888. 

11.  Melzer,  S.  J.,  Berl.  klin.  Wochenschr.,  1888,  Nr.  8. 

12.  Maybaum,  J.,  Archiv  f.   Verdatiungskrankh.,  Bd.  i,  Heft  4. 

13.  Koerner,  Deutsches  Archiv  f.  klin.  Med.,  Bd.  xxxiii. 

14.  Johannessen,  Zeitschr.f.  klin.  Med.,  Bd.  x,  S.  274. 

15.  Cantarono,  G.,  Neurolog.  Centralbl.,  Bd.  iv,  1885. 

16.  Bourneville  et  Seglas,  "  Du  Merycisme,"'\/4r(:/^.  de  Netirologie,  Paris, 
1883. 

17.  Hubbard,  W.  A.,  Medical  Record,  July  31,  1886,  p.  122. 

18.  Ponsgen,  "Die  motorischen  Verrichtungen  des  menschlichen  Magens," 
Strassburg,  1882,  p.  127. 

19.  Dehio,  "  Singultus  als  Reflexneurose,"  Berlin,  klin.  Wochenschr.,  1889. 

20.  Delamarre,  "  Des  Crises  Gastriques  dans  I'Ataxie  Locomotrice,"  These 
de  Paris,  1866. 

21.  Dubois,  "  Crises  Gastriques  dans  I'Ataxie  Locomotrice,"  These  de  Paris, 
1868. 

22.  Edlefsen,  "  Ueber  Hasten  und  Magenhusten,"  Deutsches  Arch.f.  klin. 
Med.,  Bd.  xx. 

23.  Einhorn,  "  Eine  neue  Methode  der  directen  Magenelektrisation,"  Berl. 
klin.  Wochenschr.,  1891. 

24.  Einhorn,  "  Weitere  Erfahrungen  iiber  die  directe  Elektrisation  des 
Magens,"  Zeitschr.  f.  klitt.  Med.,  1893. 

25.  Erb,  "  Handbuch  der  Elektrotherapie,"  2.  Aufl.,  Leipzig,  1886. 

26.  Erb,  "Ueber  die  wachsende  Nervositat  unserer  Zeit."  Prorectorats- 
rede.     Heidelberg,  1893. 

27.  Ewald,  "  Neurasth.  dyspeptica,"  Verhandlungen  des  Congresses  fiir 
innere  Medizin,  1884. 

28.  Ewald,  "  Enteroptose  und  Wanderniere,"  Berl.  klin.  Wochenschr.,  1890. 

29.  Felix,  "  Des  Troubles  Gastriques  dans  I'Ataxie  Locomotrice,"  These  de 
Paris,  1880. 

30.  Fenwick,  "  On  Atrophy  of  the  Stomach  and  on  Nervous  Affections  of 
the  Digestive  Organs,"   London,  1880. 

31.  Fleiner,  "  Ueber  die  Veranderungen  des  Nervensystems  bei  Addison'- 
scher  Krankheit,"   Zeitschr.  f.  Nervenheilkunde ,  1892. 

32.  Fleiner,  "  Ueber  die  Behandlung  einiger  Reizerscheinungen  und  Blut- 
ungen  des  Magens,"  Verhandlungen  des  XII  Congresses  fiir  innere  Medizin, 
Wiesbaden,  1893. 

33.  Fleiner,  "  Erfahrungen  iiber  die  Therapie  der  Magenkrankheiten," 
Samnihing  klin.  Vortrdge,  1894,  Nr.  103. 

34.  Fleiner,  "  Ueber  Neurosen  gastrischen  Ursprungs  mit  besonderer  Be- 
riicksichtigung  der  Tetanie  und  ahnlicher  Krampfanfalle,"  Arch.  f.  Verdau- 
ungskrankh.,  Bd.  I,  1895. 


684  NEUROSES    OF    THE    STOMACH. 

35.  Flemming,  "  Ueber  Pracordialangst,"  Allgem.  Zeitschr.  f.  Psychiairie, 
Bd.  V,   1848. 

36.  Fothergill,  cfr.  Krakauer,  "  Der  Chron.  Morb.  Brightii,  der  atherom. 
Process  und  das  Blut  in  ihren  Wechselbeziehungen,"  Berlin  und  Neuwied, 
1892. 

37.  V.  Frankl-Hochwart,  "  Die  Tetanie,"  Berlin,  1889. 

38.  Freund,  E.,  "Ueber  Intoxicationserytheme,"  f'?^>«(fr  wz^<^.  Wochetischr., 

1894. 

39.  Fiirbringer,  "Ueber  ]\Iagensch\vache,"  Deutsche  jued.  Zeiiung,  1893. 

40.  Gassner,  "Ueber  die  bei  Dilat.  ventric.  vorkommenden  tonischen  Mus- 
kelkrampfe  und  epileptiformen  Anfalle."     Inaug.-Diss.     Strassburg,  1868. 

41.  Geigel  und  Abend,  "  Die  Salzsauresecretion  bei  Dyspepsia  nervosa," 
Virchow's  Archiv,  Bd.  cxxx. 

42.  Glax,  G.,  "  Ueber  den  Zusammenhang  nervoser  Storungen  mit  den 
Erkrankungen  der  Verdauungsorgane "  und  "Ueber  nervose  Dyspepsia," 
Sannnlung  klin.  Vortrage,  1882,  Nr.  223. 

43.  Goldschmidt,  E.,  "Ueber  den  Einfluss  der  Elektricitat  auf  den  gesun- 
den  und  kranken  menschlichen  ?^Iagen,"  Deutsches  Arch.f.  klm.  Med.,  1895, 
Bd.  Lvi. 

44.  Havel,  "  Des  Crises  Gastriques  dans  I'Ataxie  Locomotrice,"  These  de 
Paris,  1882. 

45.  Schiitz,  Prager  med.  Wochetischr.,  1882,  Nr.  11. 

46.  Cahn,  Deutsches  Archiv  f.  klin.  Med.,   1884,  p.  402. 

47.  De  Sere,  L.,  "  Du  Relachement  du  Pylore,"  6^12^.  des  Hop.,  1864,  No.  62. 

48.  Ebstein,  Deutsches  Archiv f.  klin.  Med.,  Bd.  xxvi,  S.  295. 

49.  Bentejac,  These  de  Paris,  1888. 

50.  Pacanowski,  Deutsches  Archiv  f.  klift.  Med.,  Bd.  XL. 

51.  Richet,  Ch.,  "  Du  Sue.  Gastrique  chez  rHomme  et  les  Animaux,"  Paris, 
1878. 

52.  Stockton,  Med.  Record,  1894. 

53.  Leven,  "  Estomac  et  Cerveau,"  Paris,  1884. 

54.  Edinger,  Deutsches  Archiv  f.  klin.  Med.,  i88r. 

55.  Klemperer,  Berlin,  klin.  Wochenschr.,  1889,  Nr.  11. 

56.  Schetty,  F.,  Deutsches  Arch.f.  klin.  Med.,  Bd.  xliv,  S.  219. 

57.  Brieger,    Detctsche  vied.  Wochetischr.,  1888,  Nr.  14. 

58.  Immermann,  Verhandlungen  des  Congresses  fiir  innere  ]\Iedizin,  Wies- 
baden, 1889. 

59.  Hayem,  Bull.  Medic  ale,  1891,  No.  87. 

60.  Huefler,  Mime hener  med.  Wochenschr.,  1889,  Nr.  33. 

61.  Adler  und  Stern,  Berl.  kliti.  Wochenschr.,  1889,  Nr.  49. 

62.  Henoch,  "  Ueber  Asthma  dyspepticum,"  ^^r/.  i'/m.  Wochetischr.,  1876, 
Nr.  18. 

63.  Hildebrandt,  W.,  "  Nervose  Storungen  im  Gefolge  von  Magenkrank- 
heiten." 

64.  Hoffmann,  A.,  "Ueber  den  Einfluss  des  galvanischen  Stromes  auf  die 
Magensaftabscheidung,"  Berliti.  klin.  Wochenschr.,  1889. 

65.  Hoffmann,  J.,  "  Zur  Lehre  von  der  T&idiXnt,'' Heidelberger  Habilitations- 
schrift,  1888. 


LITERATURE    ON    NEUROSES    OF    THE    STOMACH.  685 

66.  Jacobson  und  Ewald,  "  Ueber  Tetanie,"  Verhandlungen  des  Con- 
gresses fiir  innere  Medizin,  1893. 

67.  V.  Jaksch,  "  Epilepsia  acetonica,"  Zeitschr.f.  klin.  Med.,  Bd.  x. 

68.  Jiirgensen,  "  Ueber  Abscheidung  neuer  Formen  nervoser  Magenkrank- 
heiten,"  Deutsches  Arch.f.  klin.  Med.,  Bd.  XLiii. 

69.  Kaufmann,  J.,  "  Zwei  Falle  geheilter  pernicioser  Anamie,  nebstBemerk- 
ungen  zur  Diagnose  und  Therapie  dieser  Krankheit,"  Berl.  kliti.  Wochenschr., 
1890,  Nr.  10. 

70.  Kussmaul,  "  Ueber  die  Behandlung  der  Magenerweiterung  durch  die 
Magenpumpe,"  Deutsches  Arch.f.  klin.  Med.,  1869,  Bd.  vi. 

71.  Kussmaul,  "  Die  peristaltische  Unruhe  des  Magens,"  Samvilung  klin. 
Vortrdge,  1880,  Nr.  181. 

72.  Kutneff,  "  Neurasthenie,  Herabsinken  von  Bauchorganen  und  gastro- 
intestinale  Atonie,"  Ref.  in  \.h.&  Jahresberichte,  1894,  Bd.  Ii. 

73.  Laffitte,  "  Des  Crises  Gastriques,"  Gaz.  des  Hop.,  Jan.,  1894. 

74.  Leo,  "Ueber  Bulimic, "  Deutsche  med.  Wochenschr.,  1889,  Nr.  29  u.  30. 

75.  Leube,  "  Ueber  nervose  Dyspepsia,"  Deutsches  Arch.  f.  kliti.  Med., 
1878,  Bd.  XXIII. 

76.  Leven,  "  Phenomenes  Nerveux  lies  a  la  Dyspepsie,"  Gaz.  des  Hop., 
1880,  No.  40. 

yj.  Leven,  "  Phenomenes  Nerveux  qui  se  Produisent  sous  I'lnfluence  de  la 
Dyspepsie,"  ibid,,  1880,  No.  137. 

78.  Leyden,  "  Ueber  Anfalle  von  periodischem  Erbrechen,  nebst  Bemerk- 
ungen  iiber  nervose  Magenaffectionen,"  Zeitschrift f.  klin.  Med.,  Bd,  iv,  1882. 

79.  Loeb,  M.,  "Tetanie  bei  Magenerweiterung,"  Deutsches  Arch.  f.  klin. 
Med.,  1890,  Bd.  Lxvi. 

80.  Malbraiic,  "  Ueber  Behandlung  von  Gastralgieen  mit  der  inneren 
Magendusche,"  etc.,  Berl.  klin.  Wochenschr.,  1878. 

81.  Mathieu  et  Milan,  "Etude  sur  le  Pituite  Hemorragique  des  Hysteri- 
ques,"  Paris,  1896. 

82.  Mbbius,  S.  A.,  "  Ueber  die  schmerzstillende  Wirkung  der  Elektricitat," 
Berl.  klin.  Wochenschr.,  1880. 

83.  Miiller,  Fr.,  "  Tetanie  bei  Dilatatio  ventriculi  und  Achsendrehung  des 
Magens,"    Charite  Aiinale7t,  1888,  Bd.  xiii. 

84.  Muret,  "  Hyperemesis  gravidar.  und  Hysterie,"  Deutsche  tned.  Wochen- 
schr., 1893. 

85.  Naunyn,    "  Zur  Lehre  vom  Husten,"    Deutsches  Arch.  f.  kli7t.  Med., 

XXIII. 

86.  Neumann,  Deutsche  Klinik,  1861,  Nr.  3. 

87.  Nonne,  "  Beitrage  zur  Kenntniss  der  im  Verlaufe  der  perniciosen  Anamie 
beobachteten  Spinalerkrankungen,"  Archiv  f.  Psychiairie,  Sep.  S.,  Bd.  XXV. 

88.  V.  Noorden,  "  Klinische  Untersuchungen  iiber  die  Magenverdauung  oei 
Geisteskrankheiten,"     Archiv  f.  Psychiairie  und  Nervenkrankheiten,  Bd.  X. 

89.  V.  Noorden  (con),  "  Pathologie  der  gastrischen  Crisen,"  Chariik  Anfia- 
len,  1890. 

90.  Oser,  "  Die  Neurosen  des  Magens  und  ihre  Behandlung,"  Wiener  Klinik, 
1885,  Heft.  5  und  6. 

45 


686  NEUROSES    OF    THE    STOMACH. 

91.  Panecki,"  Retroflexio  uteri  und  Magenneurose,"  Therapeiitisc/ie  Monats- 
hefte,  1892. 

92.  Petitjean,  "  Contribution  a  I'Etude  des  Crises  Gastriques  dans  I'Ataxie 
Locomotrice,"  These  de  Paris,   1874. 

93.  Peyer,  A.,  "  Beitrag  zur  Kenntniss  der  Neurosen  des  Magens  und  des 
Darms,"  Correspondenzblatt  f.  Schweizer  Aerzte,  1888. 

94.  Potain,  "  Paralysie  Consecutive  a  des  Troubles  Digestifs,"  Gaz.  des 
Hop.,  1880. 

95.  Raymond,  "  Des  Dyspepsies,"  These  d'aggreg.,  1878. 

96.  Remond  (de  Metz),  "  Des  Crises  Gastriques  Essentielles,"  Arch.  Gen. 
de  Med.,  1889,  Tome  11. 

97.  Richter,  "  Ueber  nervose  Dyspepsie  und  nervose  Enteropathie,"  Berl. 
khn.  Wochenschr.,  1882. 

98.  Riegel,  F.,  "Zur  Lehre  von  der  Tetanie,"  Deutsches  Archiv  f.  klin. 
Med.,  1873,  Bd.  xii. 

99.  Rosenbach,  O.,  "  Beitrag  zur  Lehre  von  den  Krankheiten  des  Verdau- 
ungsapparates,"  Deutsche  med.  Wochenschr.,  1879  (Vagusneurose). 

100.  Rosenthal,  "  Magenneurosen  und  Magenkatarrh,"  Wien  und  Leipzig, 
1886. 

loi.  Rossbach,  "  Nervose  Gastroxynsis  als  eine  eigene  characterisirbare 
Form  der  nervosen  Dyspepsie,"  Deutsches  Archiv  f.  klin.  Med.,  Bd.  XXXIV. 

102.  Schuchardt,  "  Epileptiforme  Anfalle  bei  Magenerkrankungen,"  Allgem. 
Zeitschr.f.  Psychiatrie,  1882,  Bd.  xxxviii. 

103.  See,  G.,  "  Anwendung  der  Cannabis  indica  in  der  Behandlung  der  Neu- 
rosen und  gastrischen  Dyspepsieen,"  Deutsche  med.  Wochenschr.,  1890. 

104.  Singer,  "  Die  Rumination  beim  Menschen  und  ihre  Beziehung  zum 
Brechact,"  Deutches  Archiv j[.  klin.  Med.,  1893,  Bd,  li. 

105.  V.  Sohlern,  "  Zur  Behandlung  der  nervosen  Magenkrankheiten,"  Berl. 
klin.  Wochenschr.,  1891. 

106.  Stiller,  "  Die  nervosen  Magenkrankheiten,"  Stuttgart,  1884. 

107.  Strauss,  "  Des  Ecchymoses  Tabetiques  a  la  Suite  des  Crises  Doulou- 
reuses,"  Arch,  de  Neur.,  1880-81. 

108.  Strauss,  "Ueber  das  Vorkommen  von  Ammoniak  im  Mageninhalt,"  etc., 
Berl.  klin.  Wochenschr.,  1893. 

109.  Talma,  "  Zur  Kenntniss  des  Leidens  des  Bauchsympathicus,"  Deutsches 
Archiv  f.  klin.  Med.,  1892,  Bd.  XLIX ;  Zeitschr.  f.  klin.  Med.,  1884,  Bd.  viii, 
S.  407. 

no.  Trousseau,  Med.  Klinik  des  Hotel  Dieu  in  Paris,  Bd.  iii,  1868, 
Cap.  67. 

111.  C.  Westphal,  "Ueber  Agarophobie,  eine  neuropathische  Erscheinung," 
Archiv  f.  Psychiatrie,  1872,  Bd.  iii. 

1 12.  Westfalen,  ''Kopfschmerzen  gastrischen  Ursprungs,"j5^r/.  klin.  Wochen- 
schr., 1 89 1, 

113.  Bouveret,  L.,  "  Traite  des  Maladies  de  I'Estomac,"  Paris,  1893,  p.  654. 

1 14.  Alt,  Konrad,  "  Ueber  das  Bestehen  von  Neurosen  und  Psychosen  auf  dem 
Boden  von  chronischen  Magenkrankheiten,"  ^r^^zVy.  Psychiatrie  u.  Nerven- 
krankheiten,  Bd.  xxiv,  1892. 


LITERATURE    OX    THE    GASTRIC    NEUROSES.  687 

115.  Bamberger,  "  Tetanic  bei  Magendilatation."     Bericht  der  "  Contracture 
Mortelle  d'Origine  Gastrique."     Gaz.  Hebdom.,  1889. 

116.  Boas,    "  Ueber    periodische   Neurosen    des    Magens,"    Deutsche    vied. 
Wochenschr.,  1889. 

117.  Bouveret  et  Devic,    "  Recherches  Cliniques  et  Experimentales  sur  la 
Tetanie  d'Origine  Gastrique,"  Revue  de  Med.,  1892,  xil. 

118.  Briigelmann,  W.,   "Ueber  Hemicrania    gastrica,"  Berl.  kli}i.  JVochen- 
schr.,  1883. 

119.  Buch,    "Wirbelweh,    eine    neue    Form  der   Gastralgie,"    Pefersb.   ined. 
Wochenschr.,  1889. 

120.  Burkart,  "  Zur  Pathologie  der  Neurasthenia  gastrica,"  Bonn,  1S92. 

121.  Cartier,     "  Action   de   la  Teinture  de  Jode    Centre   le   Vomissement," 
L'  Union  Med.,  1889. 

122.  Chantemesse  et  Le  Noir,  "  Nevralgies  Bilaterales  et  Dilatation  de  I'Es- 
tomac,"  Arch.  Gen.  de  Med.,  1885. 

123.  Charcot,     "Des    Crises     Gastriques    Tabetiques    avec    A'omissements 
Noirs,"  Gaz.  Med.  de  Paris,  Sept.,  1892. 

124.  Charcot,  "  Le9ons  sur  las  Maladies  du  Systeme  Xerveux,"  1886. 

125.  Cordes,  "  Die  Platzangst,  Symptom  einer  Erschopfungsneurose,"  Arch, 
f.  Psych.,  Bd.  in,  1872. 

126.  Cordes,  "  Einiges  iiber  Platzangst,"  Archiv  f.  Psych.,  Bd.  X,  1880. 

127.  Debove,  "  Crises  Gastriques  non  Tabetiques,"  Bull,  de  la  Soc.  Med.  des 
Hop.,  1889. 

128.  Biernacki,  Berl.klin.  Wochenschr.,  1891,  Nr.  25  und  26. 

129.  Jones,  Allen  A.,  "  Gastric  Conditions  in  Renal  Disease,"  New  York  Med. 
Journal,  Jan.  19,  1895. 

130.  Rosenstein,  Berl.  klin.  Wochenschr.,  1890,  Nr.  13. 

131.  Gans,  Edg.,  IX  Congress  f.  innere  Medizin,  Wiesbaden,  1890. 

132.  Pidoux,  "  Rapport  de  I'Herpetisme  et  des  Dyspepsies,"  L'  Ufiion  Med., 
1866,  p.  235. 

133.  Jacobi,  A., Transactions  of  the  Association  of  American  Physicians,  1894. 

134.  Hyde,  "Twentieth  Century  Practice  of  Medicine,"  vol.  v,  p.  170. 


CHAPTER  X. 
SENSORY  NEUROSES. 

HYPERESTHESIA. 
Hyperesthesia  depends  upon  a  morbid  increase  in  the  irritabiHty 
of  the  sensory  nerves  of  the  stomach.  It  is  probably  a  neurosis 
of  the  vagus,  and  a  mild  form  of  gastralgia.  Clinically,  the  two 
forms  of  gastric  sensibility,  viz.,  gastralgia  and  hyperesthesia,  are 
differentiated  by  the  following  facts  :  The  unpleasant  sensation  of 
pressure,  fullness  and  pain  in  the  epigastrium  with  eructations, 
nausea,  and  vomiting,  occur  in  hyperesthesia  only  after  the  inges- 
tion of  food;  that  is,  there  must  be  a  digestive  stimulation  of  the 
mucosa.  The  distress  occurs  only  after  meals,  very  rarely  with  an 
empty  stomach ;  but  in  gastralgia  the  pains  and  other  distress 
occurs  with  equal  intensity  in  the  full  as  well  as  in  the  empty 
stomach  ;  digestive  irritation  is  not  necessary  to  cause  gastralgia. 
Hyperesthesia  lasts  several  days,  weeks,  or  even  months,  wuth 
uniform  or  gradually  increasing  intensity,  and  during  this  time 
dyspeptic  symptoms  occur  daily  after  every  meal;  in  gastralgia, 
however,  the  pains  last  only  during  the  attacks,  generally  for  a  few 
hours  only.  In  the  intervals  between  the  attacks  the  excitability 
of  the  nerves  is  so  completely  arrested  that  even  strong  irritation — 
like  the  overloading  of  the  stomach  with  food — does  not  cause  a 
return  of  the  pain.  The  various  acts  constituting  normal  diges- 
tion, the  movements  of  the  gastric  wall  and  of  the  contents  of  the 
digestive  tract  are  phenomena  of  which  a  healthy  person  is  not 
conscious,  but  they  may  be  perceived  by  patients  with  increased 
sensitiveness  of  the  gastric  nerve  endings.  As  a  result  of  this 
nervous  state,  sensations  reach  consciousness  from  these  localities 
which  in  the  normal  being  would  not  pass  the  threshold  of  con- 
sciousness. The  disturbance  of  the  nerves  need  not  necessarily  be  in 
the  end  distributions  of  the  stomach  ;  they  may  be  in  the  nerve  itself 
or  in  the  central  organ.  Most  frequently  the  seat  may  be  in  the  peri- 
pheral nervous  end  organs  in  the  stomach  ;  these  are  the  cases  that 
have  been  caused  by  improper  mode  of  life  and  various  insults  to 


SYMPTOMS    OF    GASTRIC    HYPERESTHESIA.  689 

the  mucosa.  In  other  rare  cases  the  gastric  hyperesthesia  may  be 
a  perception  due  to  increased  excitabihty  of  the  nervous  centers. 
In  order  to  intelligently  appreciate  the  sufferings  of  patients  with 
increased  sensibility  it  is  necessary  to  bear  in  mind  that  the 
increased  irritability  brings  about  the  perception  of  transactions 
into  the  digestive  tract,  which  in  themselves  are  not  pathological, 
and  if  present  to  the  same  degree  in  a  healthy  individual  would  not 
be  perceived.  The  natural  process  of  digestion  and  absorption  in 
such  patients  is  a  train  of  uninterrupted  distressing  sensations.  The 
patients  themselves  generally  misinterpret  their  condition  or  exag- 
gerate it,  and  as  a  consequence  of  the  various  impressions  that 
they  perceive,  assume  that  they  suffer  from  severe  organic  disease. 
They  often  become  hypochondriacal.  Hyperesthesia  may  be  an 
independent,  idiopathic  or  secondary,  symptomatic  neurosis. 

Causation. — The  primary  idiopathic  form  occurs  very  frequently 
as  an  accompaniment  to  chlorosis  and  anemia,  particularly  with 
women  and  young  girls.  Also  after  repeated  overloading  of  the 
stomach  with  indigestible  food.  Long-continued  use  of  very  salty 
or  acid  or  spiced  foods,  and  the  ingestion  of  very  hot  or  very  cold 
drinks  after  long  fasting,  and  in  debilitated  states  following  excesses 
(in  venere  et  Baccho).  It  has  been  observed  to  occur  also  after 
chloroform  narcosis.  Secondary  hyperesthesia  occurs  with  hyper- 
acidity and  supersecretion  in  hysterical  patients,  also  in  neuras- 
thenia and  tabes.  Gastralgia  may  follow  hyperesthesia,  and  there 
are  cases  in  which  both  neuroses  may  be  present  simultaneously. 

Symptomatology. — Patients  with  this  neurosis  frequently  feel 
the  pulsations  of  the  abdominal  aorta,  and  complain  of  beating  and 
pulsating  in  the  stomach.  Then,  again,  they  have  a  feeling  of  heat 
or  cold,  or  a  gnawing,  burning  sensation,  and  an  impression  of  rest- 
lessness through  the  entire  stomach.  The  ingestion  of  food,  no 
matter  of  what  consistency,  causes  a  sensation  of  discomfort,  full- 
ness, nausea,  and  even  vomiting.  These  sensations  may  increase  to 
a  typical  gastralgia,  and  are.  felt  only  during  the  first  period  of 
digestion,  or  they  may  last  as  long  as  food  is  contained  in  the 
stomach.  Some  patients  complain  for  a  while  even  after  food 
has  left  the  stomach.  The  pains  are  absent  in  the  morning,  when 
the  stomach  is  entirely  empty.  If  the  hyperesthesia  depend  upon 
hyperchylia,  the  pains  do  not  become  pronounced  until  the  second 
period  of  gastric  digestion,  when  the  acidity  of  the  gastric  chyme 
reaches  its  highest  degree.     In  some  cases  of  hyperesthesia  it  may 


690  SENSORY    NEUROSES. 

happen  that  the  distress  is  temporarily  relieved  by  the  ingestion  of 
albuminous  food  or  the  taking  of  alkalies.  The  burning,  sticking, 
and  beating  in  the  stomach  may  be  accompanied  by  bulimia. 
These  gastric  symptoms  are  generally  accompanied  by  other 
nervous  phenomena  which  are  probably  symptoms  of  the  funda- 
mental etiological  disease  ;  thus  we  meet  with  migraines,  cephalalgia, 
and  neuralgias  in  other  parts  of  the  body,  etc.,  etc.  The  emesis 
which  occurs  in  hyperesthesia  induces  the  patients  to  restrict  their 
diet  more  and  more,  whereby  the  general  nutrition  and  bodily 
resistance  become  very  much  reduced.  Concerning  the  appetite 
and  the  foods  which  are  best  digested,  the  patients  show  the  most 
manifold  contrasts.  Some  of  them  feel  more  distress  after  liquids 
than  after  solids.  The  appetite  does  not  seem  much  affected  ;  some 
patients  have  an  intense  feeling  of  hunger.  There  are  no  very 
constant  anomalies  of  motility  or  secretion.  The  bowels  are 
generally  constipated. 

Prognosis. — The  prognosis  is  favorable,  as  the  hyperesthesia 
ceases  when  the  detrimental  and  irritating  conditions  which  excite 
the  sensibility  of  the  stomach  can  be  kept  away,  and  when  the 
fundamental  disease  can  be  removed. 

Diagnosis. — The  affection  may  be  confounded  with  gastralgia, 
and  with  the  painful  symptoms  of  organic  gastric  diseases.  From 
gastralgia  it  can  be  distinguished  by  the  fact  that  the  symptoms 
occur  daily  for  a  long  time,  regularly  after  each  meal,  and  that  they 
are  absent  when  the  stomach  is  empty.  Gastralgia  occurs  only 
spasmodically,  rarely  lasts  longer  than  several  hours,  and  is  of 
equal  severity  in  an  empty  as  in  a  full  stomach.  The  intervals 
between  the  attacks  are  perfectly  free  from  gastric  distress. 
Concerning  the  differential  diagnosis  between  hyperesthesia  and 
the  distress  of  diseases  of  the  stomach  connected  with  anatomical 
alterations,  we  refer  to  the  differential  points  stated  in  the  diagnosis 
of  gastralgia.  We  might  emphasize  here  that,  in  the  organic  dis- 
eases, the  pains  are  entirely  absent  when  the  stomach  is  empty. 
Atrophic  gastritis  forms  an  exception  to  this  rule.  The  intensity 
of  the  pains  is  influenced  by  the  quality  of  the  food,  which  is  not 
the  case  in  hyperesthesia,  and  that  organic  diseases  are  mostly 
associated  with  tolerably  constant  disturbances  of  secretion  and 
motility. 

Treatment. — The  treatment  will  be  directed  in  the  first  place  to 
the  correction  of  the  underlying  fundamental  disease.     Wherever 


TREATMENT    OF    HYPERESTHESIA.  69 1 

this  is  not  possible,  or  wherever  an  idiopathic  form  of  hyperesthesia 
is  present,  all  irritants  which  can  exert  detrimental  influence  upon 
the  stomach  must  be  excluded.  All  bodily  and  mental  exertion 
must  be  avoided.  In  severe  cases,  the  Weir  Mitchell  rest-cure,  to- 
gether with  a  Leube  ulcer  cure,  has,  in  our  experience,  been  very 
efficacious.  Hot  moist  applications  to  the  stomach  are  very  sooth- 
ing. In  a  very  pronounced  case  of  gastric  hyperesthesia  in  a  col- 
league, which  returned  regularly  whenever  he  was  under  great 
mental  strain,  the  symptoms  disappeared  entirely  after  a  sojourn  at 
the  seashore  for  one  month.  Galvanization  is  a  capital  method  of 
treating  this  affection.  The  intragastric  method  may  be  used,  but 
when  the  patient  is  not  accustomed  to  the  swallowing  of  the 
electrode  we  have  obtained  good  results  from  the  external  applica- 
tion of  the  large  abdominal  plates.  Excessive  use  of  tea,  coffee, 
tobacco,  and  alcohol  must  be  avoided,  as  these  things  have  been 
known  to  keep  up  a  hyperesthesia.  Rosenheim  has  suggested  the 
following  treatment  {^Berlin,  klin.  Wochenschr.,  1890)  internally: 

K .     Argenti  nitras, 0.2         grs.  iij. 

Aquae  menthse    pip  , loo.o        5  iij-            M. 

SiG. — Two  teaspoonfuls  in  a  wineglassful  of  water,  on  an  empty  stomach,  in  the 
morning,  and  a  half  hour  before  each  meal. 

The  patient  must  be  kept  in  bed,  and  warm  cataplasms  applied 
to  the  epigastrium.  The  diet  consists  of  milk  taken  by  table- 
spoonful  doses,  later  on  soft  eggs,  and  scraped  beef  and  dipped  toast. 
When  the  stomach  becomes  more  resistant,  the  patient  can  return 
to  solid  food.  To  remove  the  cause,  Rosenheim  advises  treat- 
ment of  the  general  underlying  affection,  bodily  and  mental  rest, 
and  hydrotherapeutic  measures.  Severe  hyperesthesia  is  some- 
times relieved  by  bromid  of  strontium  and  codein.  We  have  also 
obtained  very  good  results  from  spraying  the  stomach  with  a  solu- 
tion of  morphin,  cocain,  and  menthol.  In  doing  this,  a  spray  must 
be  used  by  which  we  can  tell  the  exact  amount  of  cocain  and 
morphin  which  reaches  the  stomach  with  the  spraying  liquid.  It 
is  well  not  to  put  more  into  the  spray  than  we  wish  to  put  into 
the  stomach,  otherwise,  the  patient  may  absorb  too  much  cocain 
and  morphin. 

Gastric  idiosyncrasies  are  those  peculiar  forms  of  hyperesthe- 
sia in  which  neuropathic  and  sometimes  perfectly  healthy  persons 
have  morbid  sensations  only  after  ingesting  certain  foods.     These 


692  SENSORY    NEUROSES. 

sensations  consist  of  headache,  light  fever,  skin  erythema,  and 
urticaria.  The  author  has  observed  persons  who  developed  urti- 
caria after  eating  crabs,  potatoes,  cheese,  or  strawberries.  One  of  our 
patients  regularly  develops  an  acute  acne  whenever  she  eats  cheese. 
Another  patient  regularly  develops  fever  whenever  he  partakes 
of  crabs.  Although  a  heightened  irritability  of  the  sensory  nerves 
may  be  instrumental  in  the  development  of  these  idiosyncrasies,  it 
is  ver)'-  plausible  that  auto- intoxication  plays  a  very  important  role 
in  them.  It  is  probable  that  in  individuals  who  develop  urticaria 
after  eating  certain  foods,  there  must  be  micro-organisms  that 
develop  toxins  from  these  foods,  w^hich,  in  turn,  act  in  the  manner 
indicated.  Pick  states  that  his  cases  suffered  also  from  constipa- 
tion, which  naturally  favors  the  putrefaction  of  the  ingesta.  Acting 
upon  the  theory  of  auto-intoxication  caused  by  intestinal  putrefac- 
tion, Pick  very  strongly  recommends  the  internal  use  of  creosote. 
(See  "  Albu.  Auto-intoxicationen  des  Intestinaltractus,"  part  on 
The  Skin,  p.  88);  also  p.  396  of  this  volume. 

GASTRALGIA  (Cardialgia,  Gastrodynia). 
Gastralgia,  or  neuralgia  of  the  stomach,  occurs  in  periodical  and 
spasmodical  attacks  of  severe  gastric  pain,  alternating  with  inter- 
vals of  freedom  from  pain.  Pains  of  greater  or  less  intensity  occur 
with  all  gastric  diseases,  particularly  with  ulcer,  carcinoma,  gas- 
tritis atrophicans,  and  toxic  gastritis.  These  pains  are  a  consequence 
of  the  anatomical  alterations  which  these  organic  diseases  effect  in 
the  gastric  w^all,  brought  about  most  probably  by  exposure,  dis- 
tortion, and  compression  or  inflammation  of  the  sensory  gastric 
nerves.  Such  pains  have  been  described  in  the  chapter  on  various 
Organic  Diseases  of  the  Stomach.  Gastralgic  pain  results  from  func- 
tional, not  from  structural  disturbances  of  the  sensory  nerves.  Gas- 
tralgia is  characterized  by  the  irregular  intervals  in  which  it  occurs, 
and  its  independence  of  the  quality  and  quantity  of  the  ingesta. 
The  attacks  come  on  either  suddenly,  or  there  may  be  such  pre- 
monitor}'  symptoms  as  feeling  of  pressure  and  fullness  in  the  stom- 
ach, eructation,  nausea,  vomiting,  headache,  and  salivation.  The 
pains  have  a  gnawing,  boring,  burning,  tearing,  or  cramp-like  char- 
acter. They  are  felt  principally  in  the  epigastric  region.  In  some 
cases  the  pain,  radiates  to  the  hypochondriac  regions,  the  entire 
abdomen  and  back,  and  may  be  accompanied  by  unmistakable 
signs  of  collapse  and  the  feeling  of  impending  dissolution.     The 


CAUSATION    OF    GASTRALGIA.  693 

pains  occur  as  well  after  food  that  is  easily  digestible  as  after 
indigestible  food. 

In  some  hysterical  patients  the  so-called  "  clavus  hystericus,"  a 
sharply  localized  pain,  as  if  a  nail  were  driven  into  a  part,  is  well 
described  by  the  sufferer.  There  is  also,  in  some  of  these  cases,  a 
sudden  and  transient  sensation  as  if  a  tremendous  ball  were  rising 
in  the  throat  (globus  hystericus).  Nausea  and  vomiting,  as  well  as 
bulimia  and  an  urgent  desire  to  urinate,  are  occasional  symptoms. 
The  paroxysms  may  last  a  few  minutes  or  several  hours,  and 
extend  through  the  entire  night;  the}^  may  begin  at  any  hour  of 
the  day  or  night.  The  intervals  of  relief  may  amount  to  days, 
weeks,  or  months.  We  have  observed  a  number  of  cases  of  ma- 
larial gastralgia  in  which  the  attacks  occurred  at  regular  intervals, 
and  could  be  distinctly  associated  with  an  evolution  of  the  charac- 
teristic malarial  parasite  in  the  blood.  These  malarial  gastralgias 
are  not  infrequent  in  fishermen,  and  even  sportsmen  who  sojourn 
for  weeks  along  the  shores  of  the  Chesapeake  Bay  in  Maryland. 
In  a  wealthy  patient  of  this  city,  the  gastralgic  attacks  persisted, 
notwithstanding  the  most  careful  treatment,  until  the  patient  could 
be  persuaded  to  give  up  his  ducking  sport  on  the  Chesapeake  Bay. 
The  attacks  occur  generally  without  any  demonstrable  cause. 
As  a  rule,  only  one  attack  occurs  in  the  day,  but  there  may  be  as 
many  as  four  in  one  day.  The  end  of  the  attack  may  culminate  in 
very  profuse  vomiting,  which  brings  a  great  relief,  the  pains  ceasing 
thereafter  as  rapidly  and  suddenly  as  they  came  on.  Gastralgia 
may  be  a  primary  idiopathic  and  independent  disease  or  a  sec- 
ondary reflex  neurosis. 

Causation. — The  gastralgia  is  frequently  a  result  of  motor 
or  secretory  neuroses, — of  gastrospasm,  pylorospasm,  and  cardio- 
spasm, hyperacidity,  and  supersecretion.  The  root  of  the  vagus 
nerve  may  be  irritated  by  functional  and  anatomical  diseases  of  the 
medulla  and  adjacent  portions  of  the  central  nervous  system. 
Boas  {loc.  cit.  ii,  S.  214)  enumerates  the  following  causes  of  gas- 
tralgia :  (i)  Those  that  attack  the  stomach  itself  and  its  immediate 
surrounding.  (2)  Central  causes.  (3)  Infections  and  intoxications. 
(4)  Reflex  causes  emanating  from  other  organs.  (5)  Neurasthenia 
and  hysteria,  (a)  The  causes  that  emanate  from  the  stomach  and 
its  immediate  surroundings  are  gastric  ulcer,  gastric  carcinoma,  gas- 
tritis acida  and  atrophicans,  various  forms  of  perigastritis,  and  peri- 
tonitic  adhesion  with  the  pancreas,  liver,  gall-bladder,  spleen,  and 


694  SENSORY    NEUROSES. 

transverse  colon,  and  other  portions  of  the  intestines.  Furthermore, 
hypersecretion  and  gastroxynsis,  tumors  of  neighboring  organs  and 
pancreatic  cysts,  {b)  Of  the  central  causes  he  mentions  the  attacks 
occurring  with  tabes  ("  crises  gastriques  ").  In  myelitis  and  brain 
tumors,  gastralgic  pains  have  been  observed,  (c)  Infections  and 
intoxicants  may  cause  gastralgia.  Of  the  first,  a  prominent  cause 
of  infection  in  our  latitude  is  malaria,  either  in  its  outspoken 
form  or  in  its  masked  and  latent  type.  Of  intoxicants,  nicotin 
poisoning  and  the  auto-intoxication  associated  with  uric  acid  and 
gout  are  well-known  causative  factors.  {d)  Among  the  reflex 
causes  emanating  from  other  organs,  diseases  of  the  genito-urinary 
organs  occupy  the  first  place  in  both  sexes.  Prominent  among 
these  are  displacements  of  the  uterus,  inflammations  of  the  ovaries 
and  tubes,  and  uterine  and  ovarian  neoplasms.  (Panecki,  "  Retro- 
flexio  uteri  und  Magenneurosis,"  TJicrapciit.  MonaisJiefte,  1892,  S. 
79.)  Independent  organic  gastric  diseases  that  occur  simultane- 
ously must  be  carefully  differentiated  from  the  typical  gastralgia. 
Gastralgias  may  be  associated  with  genito-urinary  diseases  in  the 
male.  (Peyer,  "Ueber  Magenaffectionen  b.  mannlichen  Genitallei- 
den,"  Volkniann' s  Sainml.  klin.  Vortr.,  No.  356.)  The  gastralgias 
which  occur  as  a  consequence  of  enteroptosis  have  been  fully  con- 
sidered in  the  chapter  on  Gastroptosis.  {e)  Stomach  neuralgia  which 
occurs  in  hysterical  and  neurasthenic  persons  without  any  apparent 
cause,  and  those  which  occur  in  anemic  patients,  should  prompt  a 
very  careful  examination  before  we  decide  that  there  is  no  real 
organic  trouble  at  the  foundation  of  the  gastralgia.  Occasionally  we 
may  find  that  gastralgias  occur  with  small  median  hernise  of  the 
linea  alba.  Whenever  motor  insufficiency  exists  with  these  herniae, 
we  presume  that  the  omentum  is  fixed  in  the  hernial  sac. 
Such  cases  have  been  recently  reported  by  Rosenheim  {Berlin, 
klin.  Wochensclir.,  1897,  No.  1 1).  Horner  ("  Ueber  Cardialgia,  Verur- 
sacht  d.  prae-peritoneale  Lipome,"  Prag.  vied.  Wochensclir.,  1892, 
S.  310)  reports  a  case  of  severe  gastralgia  caused  by  preperitoneal 
lipomata.  These  hernise  of  the  linea  alba  can  be  treated  success- 
fully only  in  an  operative  or  orthopedic  method  (Bandages). 

F.  Bardenhauer  ("  Ueber  den  epigastrischen  medianen  Bauch- 
bruch,"  in  Gesanivielte  Beitrdge  a.  d.  Gebiete  d.  CJiir.  n.  Medizin, 
etc.,  Wiesbaden,  1893,  S.  35),  Vulpius  [Beitr.  z.  klin.  Chirurg.,  Bd. 
VII,  H.  i),  and  Roth  {Archiv  f.  klin.  Chirurg.,  Bd.,  xlii,  H.  i,  S.  i) 
consider  this  subject  from  the  surgical  side.     It  is  possible  that  in 


IDIOPATHIC  GASTRALGIA.  695 

some  cases  of  gastralgia,  in  which  we  can  not  find  other  diseased 
conditions  which  may  have  caused  the  affections,  secondary  ana- 
tomical changes  in  the  stomach  may  exist.  Among  these  are  ero- 
sions without  hemorrhage,  follicular  inflammation,  adhesions  with 
neighboring  organs,  and  cicatrices.*  These  conditions  can  not 
be  excluded  with  certainty,  because  they  may  not  cause  symptoms 
for  a  long  time.  The  author  advises  every  caution  in  the  diag- 
nosis of  idiopathic  gastralgia,  as  many  a  case  that  is  diagnosed  as 
a  genuine  form  of  gastralgia  of  this  character  is  found  after  a  very 
thorough  examination  to  be  a  result  of  some  anatomical  change,  or 
a  motor  or  secretory  neurosis  of  the  stomach,  or  of  a  disease  of 
some  other  organ.  Idiopathic  gastralgia  should  only  be  diag- 
nosed when  symptoms  and  indications  of  other  diseases  can  not  be 
discovered  after  an  exhaustive  anamnesis,  and  repeated  thorough 
examination  by  means  of  the  most  modern  methods,  and  instituted 
during  the  intervals  between  the  attacks  when  the  patient  is  free 
from  suffering.  The  author  has  rarely  made  the  diagnosis  of  idio- 
pathic gastralgia. 

Idiopathic  gastralgia  may  occur  in  connection  with  chlorosis, 
anemia,  chronic  nicotin  poisoning,  nephritis,  incipient  tuberculosis, 
and  convalescence  from  continued  fevers,  and  also  as  a  result  of 
alcoholic  and  sexual  excesses.  The  gastralgias  which  occur  with 
arthritis,  malaria,  and  chronic  rheumatism  are  particularly  inter- 
esting from  an  etiological  point  of  view.  We  have  repeatedly 
observed  that  gastralgic  attacks  in  gout  may  take  the  place  of  an 
expected  acute  attack  of  the  joints.  The  association  of  malaria 
with  gastralgia  can  be  established  beyond  a  doubt  by  the  blood 
examination  for  the  malarial  parasite,  and  this  kind  of  gastralgia 
can  be  cured  by  the  administration  of  quinin  and  sometimes  of 
arsenic,  and  ceases  entirely  if  the  patient  removes  to  an  environ- 
ment that  is  free  from  malaria.  The  occurrence  of  gastralgia 
during  gout  has  been  explained  by  some  by  assuming  that  the 
deposits  of  uric  acid  and  uric  acid  salts  actually  occur  in  the  walls 
of  the  stomach  and  thereby  irritate  the  endings  of  the  sensory 
nerves.  This  theory  explains  that  gastralgia  may  occur  vicariously 
in  place  of  expected  attacks  of  gout. 

*  A  negro  suffering  from  the  most  intense  gastralgia  with  hyperacidity  was  operated 
on  at  the  Maryland  General  Hospital,  by  Dr.  John  D.  Blake,  upon  the  author's  ad\ice. 
The  stomach  was  bound  to  the  liver,  diaphragm,  and  transverse  colon  by  numerous  adhe- 
sions, those  going  to  the  liver  being  inseparable. 


696  SENSORY    NEUROSES. 

Secondary  Gastralgia. — Cases  of  this  type  have  been  reported 
which  were  v^ery  severe  and  obstinate  during  life,  and  in  which 
tumors  were  found  at  the  autopsy  drawing  upon  or  compressing  the 
fibers  of  the  vagus  and  sympathetic.  It  has  been  observed,  also,  in 
Basedow's  disease,  but  is  more  frequently  the  result  of  direct  or  indi- 
rect irritation  of  the  roots  of  the  vagus  nerve  in  consequence  of  or- 
ganic or  functional  diseases  of  the  spinal  cord  or  brain.  We  have 
already  referred  to  the  frequent  attacks  of  gastralgia  occurring  in 
tabes,  which  have  recently  been  explained  by  a  sclerotic  degenera- 
tion of  the  nucleus  and  of  the  main  stem  of  the  vagus  (Kahler, 
Oppenheim,  Demange,  Dejerine).  The  gastric  crisis,  which  we 
have  described  elsewhere,  demands  a  greater  interest  because  it 
may  occur  in  tabes  as  an  initial  symptom  when  the  other  char- 
acteristic signs,  such  as  absence  of  the  tendon  reflexes,  rigidity  of 
the  pupils,  and  Romberg's  symptom,  are  not  yet  present,  and  in 
some  cases  the  typical  ataxia  has  not  been  known  to  occur  for  from 
six  months  to  a  year  after  critical  gastralgias  of  this  kind.  Erb  has 
established  a  very  probable  causal  relation  between  syphilis  and 
tabes,  and  the  hope  has  been  expressed  that  these  early  gastric  crises 
should  stimulate  exhaustive  clinical  examinations  of  the  patients 
with  a  view  to  combatting  the  disease  by  mercury  and  iodids  at  a 
time  when  the  spinal  changes  are  not  far  progressed.  Leyden  has 
described  gastralgia  with  subacute  myelitis,  and  Oser  with  myelitis 
due  to  compression. 

Symptomatology. — The  symptoms  of  the  attacks  are  generally 
quite  characteristic,  and  the  course  so  typical  that  they  can  not  be 
misinterpreted.  Prodromal  symptoms,  such  as  depressed  spirits, 
headache,  salivation,  nausea,  pressure,  and  fullness  in  the  stomach 
may  occur,  but,  as  a  rule,  are  not  observed  and  have  no  diagnostic 
value.  Generally,  the  cases  begin  very  suddenly  with  severe  gas- 
tric pains,  which  are  sometimes  so  intense  as  to  baffle  description. 
Strong  pressure  upon  the  stomach  sometimes  relieves  the  pain, — in 
fact,  the  patients  are  often  found  doubled-up  in  bed,  pressing  both 
hands  upon  the  epigastrium.  If  the  pain  has  been  caused  by  hyper- 
chylia,  it  is  relieved  by  alkalies  or  albuminous  food.  The  bowels 
are  constipated  and  the  urine  suppressed.  The  forehead  is  covered 
with  large  drops  of  cold  perspiration,  the  pulse  is  small,  occasionally 
irregular  and  accelerated.  In  rare  cases  it  has  been  reported  to 
have  been  much  retarded.  Great  prostration  and  muscular  cramps, 
and  even  general  convulsions,  have  been  known  to  follow.    At  the 


DIFFERENTIAL    DIAGNOSIS    OF    GASTRALGIA.  697 

end  of  the  attack  the  patients  usually  indulge  in  repeated  yawning, 
eructation,  and  sometimes  vomiting,  and  in  hysterical  patients  a 
copious  dilute  urine  is  sometimes  voided. 

Diagnosis. — As  idiopathic  gastralgia  can  rarely  be  logically 
diagnosed,  it  will  be  more  correct  to  consider  gastralgia  as  a  symp- 
tom, not  as  a  disease  per  se ;  although  the  fundamental  disease 
causing  it,  may  remain  obscure  or  be  missed  entirely  in  the  begin- 
ning of  the  disease,  it  may  become  pronounced  eventually.  Gas- 
tralgias  may  have  to  be  differentiated  from  the  pain  of  ulcer,  acute 
and  chronic  gastritis,  toxic  gastritis,  carcinoma,  from  rheumatism  of 
the  abdominal  muscles,  myalgia,  intercostal  neuralgia,  nephrolithi- 
asis, cholelithiasis,  and  intestinal  colic.  The  differential  diagnosis 
from  ulcer  of  the  stomach  has  been  stated  in  the  chapter  on  Ulcer. 
The  ulcer  pain  is  sharply  circumscribed  in  the  epigastrium  and 
in  the  dorsal  regions.  It  is  directly  dependent  upon  the  quantity 
and  quality  of  the  food.  Pains  from  gastric  ulcer  are  relieved  by 
rest  in  bed,  and  made  worse  by  movement.  This  pain  does  not 
occur  in  paroxysms — it  is  usually  a  lasting  discomfort.  There  may 
be  atypical  cases  of  ulcer  in  which  the  diagnosis  becomes  much 
involved.  Boas  {loc.  cit.,  S.  38)  emphasizes  the  diagnostic  value  of 
the  painful  point  situated  at  the  left  of  the  spinal  column  between 
the  tenth  and  twelfth  thoracic  vertebrae. 

Von  Leube  advises,  when  other  symptoms  are  missing,  to  treat 
the  disease  as  if  it  were  ulcer,  and  Boas  recommends  the  internal 
administration  of  nitrate  of  silver  for  three  or  four  weeks.  The 
good  result  of  both  of  these  treatments  would  speak  for  gastric 
ulcer.  The  acute  and  chronic  gastritis  are  rarely  so  painful  as 
to  be  confounded  with  gastralgia.  The  pains  of  chronic  atrophic 
gastritis  occur  only  at  a  time  when  complete  atrophy  of  the  mucosa 
has  supervened  ;  and,  inasmuch  as  the  secretion  in  gastralgia  is  never 
suppressed  or  lost,  this  factor  will  constitute  an  important  diag- 
nostic feature,  since  HCl  is,  in  a  great  majority  of  cases,  absent 
in  gastritis.  From  toxic  gastritis  the  diagnosis  is  made  by  help 
of  the  clinical  history ;  from  carcinoma,  by  means  of  ascertaining 
the  state  of  the  motility  and  secretion,  which  is,  as  a  rule,  lost  in 
carcinoma,  and  normal  in  gastralgia.  The  pains  of  carcinoma  as 
well  as  of  ulcer  increase  on  pressure  ;  in  gastralgia  they  diminish 
on  pressure,  and  in  carcinoma  we  have  anemia  and  cachexia  as 
prominent  signs.  It  has  been  said  that  the  galvanic  current  with  the 
anode  on  the  epigastrium  and  the  cathode   on  the  spinal  column 


698  SENSORY    NEUROSES. 

relieves  the  pain.  These  signs  are  not  rehable,  and  as  there  is  nothing 
typical  about  gastralgic  attacks  which  should  distinguish  them  from 
painful  paroxysms  issuing  from  other  abdominal  organs,  we  may 
say  that,  up  to  the  present  time,  no  pathognomonic  sign  or  symptom 
of  gastralgia  exists.  There  are  attacks  of  rheumatism  and  myalgia 
of  the  abdominal  muscles  which  seem  to  become  focused  in  the 
upper  part  of  the  abdomen,  so  that  they  may  be  confounded  with 
gastralgic  pains.  Myalgic  pains  may  occur  from  severe  exertion 
of  the  abdominal  musculature.  These  pains  are  increased  by 
pressing  or  pinching  the  sore  muscles  ;  they  are  not  accompanied 
by  any  gastralgic  symptoms  whatever,  are  very  much  improved  by 
rest,  and,  if  they  are  rheumatic,  by  salol  and  salicylate  of  soda. 
Intercostal  neuralgias  can  be  distinguished  by  the  excessive  and 
permanent  sensitiveness  to  pressure  which  the  affected  nerves 
exhibit  all  along  their  course  from  the  spinal  column  to  the  sternum. 
Cholelithiasis,  or  the  pains  of  an  incarcerated  or  passing  gall-stone, 
frequently  irradiate  so  prominently  to  the  epigastric  region  that 
they  are  more  marked  there  than  over  the  liver,  but  whenever  the 
stone  obstructs  the  ductus  choledochus  temporarily  the  gall-bladder 
may  be  palpable  by  its  dilatation,  and  icterus  and  clay-colored  stools 
are  evident  signs ;  but  in  those  patients  in  which  the  stone  is  im- 
pacted in  the  cystic  duct  and  does  not  completely  obstruct  it,  or 
rapidly  passes  through  it,  a  differential  diagnosis  is  difficult,  because 
the  symptoms  before  mentioned  are  absent.  But  even  in  these 
cases  great  sensibility  of  the  liver  to  pressure,  anteriorly  and 
posteriorly,  is  usually  present.  The  liver  is  usually  enlarged,  and 
there  is  a  painful  point  in  cholelithiasis  at  the  twelfth  dorsal  verte- 
bra, a  few  centimeters  to  the  right  of  the  spinal  column.  A  careful 
search  for  gall-stone  particles  must  be  made  in  the  passages.  Gall- 
stones, as  a  rule,  cause  vomiting,  while  gastralgia  does  so  rarely. 
The  differential  diagnosis  between  hepatalgia  and  gastralgia  pre- 
sents great  difficulties.  In  nephritic  colic,  the  dyspeptic  symptoms 
may  be  exactly  like  those  of  gastralgia.  The  diagnosis  between 
the  two  affections  can  be  made  with  certainty  by  careful  urinary 
examination,  for  fragments  of  calculi  and  traces  of  blood,  or  by 
catheterization  of  the  ureters  in  the  intervals.  In  intestinal  colic, 
the  pains  may  be  located  in  the  upper  part  of  the  abdomen.  They 
are  mostly  due  to  excessive  gaseous  distention  of  the  intestinal 
loops,  and  are  associated  with  constipation,  and  cease  after  the 
copious  discharge  of  gas. 


TREATMENT    OF    GASTRALGIA.  699 

Treatment. — In  the  treatment  of  gastralgia,  the  fundamental 
cause  must,  if  possible,  be  discovered  and  removed.  In  malarial 
districts  the  treatment  by  quinin  and  tonics  is  the  most  effective, 
if  the  causal  relation  can  be  established.  Chlorosis  and  anemia 
should  be  treated  by  albuminate  or  peptonate  of  iron,  ferratin, 
bonemarrow,  arsenic,  and  highly  nutritious  diet.  In  some  cases 
there  is  no  better  remedy  than  the  tincture  of  the  chlorid  of  iron. 
If  the  patient  is  an  inveterate  smoker,  he  must  be  cautioned  to 
cease  his  habit.  Enteroptosis,  gout,  and  rheumatism  must  have 
suitable  therapeutic  attention.  Disturbances  of  the  genito-urinary 
organs,  particularly  of  the  female  sexual  organs,  will  command  the 
attention  of  the  specialist.  Wherever  we  can  find  no  cause  for 
gastralgia,  the  only  thing  that  can  be  done  is  to  treat  it  sympto- 
matically.  The  most  effective  agent  in  our  experience  for  this 
purpose  has  been  the  galvanic  current.  Large  felt-covered  copper 
plates  are  dipped  in  water  as  hot  as  the  patient  can  stand  it,  the 
anode  placed  on  the  epigastrium  and  the  cathode  on  the  spinal 
column  extending  from  the  cervical  region  downward  between 
the  scapulae.  For  this  purpose  we  use  very  strong  currents,  not 
less  than  25  milliamperes.  Oser  ("  Die  Neurosen  d.  Magens," 
etc.,  Vienna  and  Leipzig,  1885)  claims  to  have  observed  cessa- 
tion of  the  pains  after  application  of  the  faradic  current.  Where 
the  pains  are  not  too  intense,  the  internal  administration  of  phos- 
phate of  codein,  ^  of  a  grain  every  three  hours,  chloral  hydrate, 
15  grs.  every  two  hours,  Dover's  powder,  tincture  or  extract  of 
hyoscyamus,  extract  of  belladonna,  and  camphorated  tincture  of 
opium  are  available  remedies.  Compound  spirits  of  ether  and  the 
ethereal  tincture  of  valerian,  20  drops  every  two  hours,  are  use- 
ful when  collapse  is  associated  with  the  pain.  Exalgin,  antipyrin, 
and  antifebrin  have  been  recommended  by  Penzoldt.  If  the  col- 
lapse is  marked,  wine,  whisky,  ether,  and  ammonia  should  be  given 
until  it  has  passed  over.  In  pains  of  great  intensity,  the  sovereign 
remedy  is  a  hypodermic  injection  of  ^  of  a  grain  ofmorphin  sulphate, 
together  with  y^^-  of  a  grain  ofatropin  sulphate  inserted  directly  into 
the  epigastric  region.  Boas  recommends  suppositories  of  extract 
of  opium  and  extract  of  belladonna.  All  of  these  agents  are 
useful  for  the  immediate  treatment  of  a  paroxysm  ;  they  probably 
have  no  curative  effect  on  the  underlying  etiological  trouble.  The 
irritability  of  the  mucosa  can  be  effectively  reduced  and  gastralgic 
attacks  sometimes   altogether  prevented  from  recurring  by  intra- 


yOO  SENSORY    NEUROSES. 

gastric  irrigation,  with  lukewarm  carbonated  water  (Malbranc, 
Kussmaul),  or  by  treating  the  mucosa  according  to  Fleiner's 
method — with  suspensions  of  bismuth  subnitrate.  We  have  seen 
excellent  results  from  irrigations  containing  bismuth  subnitrate  (5ij), 
bismuth  subgallate,  5ss  in  one  pint  of  camphor  water.  The  out- 
flowing camphor  water  must  be  measured  so  as  to  ascertain  that 
not  over  oj  remains  in  the  stomach.  Although  the  pains  of  gas- 
tralgia  are  not  influenced  directly  by  the  character  of  the  food, 
the  diet  should  be  very  bland  and  unirritating,  and  should  not  be 
taken  in  large  quantities. 

Gastralgokenosis. — Under  this  name  Boas  describes  a  painful 
emptiness  of  the  stomach  which  occurs  one  to  two  hours  after 
meals,  and  may  be  so  severe  as  to  embarrass  the  respiration  of  the 
patient.  The  paroxysms  last  but  one-quarter  to  one-half  an  hour, 
and  are  not  connected  with  bulimia.  These  attacks  are  said  to  be 
relieved  by  the  ingestion  of  milk,  bread,  etc.  One  of  the  cases  of 
Boas  developed  into  an  attack  every  time  he  drank  wine  or  cham- 
pagne, or  ate  cake.  We  have  never  seen  a  case  that  corresponds 
to  Boas'  description  of  this  malady,  and  would  suggest  that  it  is 
probably  a  gastric  hyperesthesia  associated  with  hyperperistalsis 
and  a  strong  secretion  of  HCl,  particularly  as  the  cases  reported  by 
Boas  show  that  the  reactions  for  HCl  were  quite  strong. 


ANOMALIES  OF  THE  SENSATIONS    OF  HUNGER  AND 

APPETITE. 

BULIMIA,  OR  HYPEROREXIA. 
Morbid  increase  of  the  sensation  of  hunger  may  occur  as  an 
independent  idiopathic  neurosis,  as  a  result  of  abnormal  irritability 
of  the  center  controlling  the  sensation  of  hunger,  or  as  a  symptom 
of  organic  diseases.  An  intelligent  insight  into  the  pathogenesis  of 
bulimia  is  only  possible  with  a  knowledge  of  the  origin  of  the 
sensation  of  hunger.  A  modern  physiological  theory  suggests 
that  the  hunger  center  in  the  medulla  oblongata  is  stimulated  nor- 
mally by  the  blood  as  soon  as  it  has  become  impoverished  in 
nutritive  substances,  and  that  the  sensation  of  hunger  ceases  when 
the  blood  is  saturated  with  nutritive  substances.  Stiller  and 
others  assert  that  the  sensation  of  hunger  results  from  excitation 
of  specific  hunger  nerves  in  the  stomach,  and  that  from  here  the 
sensation    is    conducted    centripetally    to    the  hunger  center,  and 


NATURE    OF    BULIMIA.  7OI 

that,  therefore,  the  normal  sensation,  as  a  rule,  is  brought  to  con- 
sciousness indirectly.  Neither  of  these  theories  is  supported 
by  satisfactory  cHnical  and  experimental  evidence.  The  appetite 
ceases  when  the  stomach  is  filled  with  food,  but  that  does  not 
imply  that  the  nutritive  materials  are  already  absorbed  into  the 
blood.  This  may  require  from  three  to  four  hours.  In  many 
gastric  diseases  the  feeling  of  hunger  is  indirectly  affected  by  the 
local  disease,  either  increased  or  diminished.  There  are  also 
general  (metabolic)  diseases  which  directly  or  indirectly  increase 
or  diminish  the  sensation  of  hunger.  In  some  persons,  even 
in  the  normal  condition,  vehement  emotional  excitations  may 
cause  a  loss  of  hunger  and  appetite,  although  the  blood  is  un- 
doubtedly impoverished  in  nutritive  substances,  so  that  we  have 
clinical  evidence  sufficient  to  demonstrate  both  a  local,  gastric,  and 
a  remote  or  central  nervous  excitation  of  hunger.  According  to 
one  hypothesis,  hunger  results  every  time  the  stomach  becomes 
entirely  empty,  and  Leo  ("  Ueber  ^nWmxd,,"  Deutsche  med.  Woch- 
enschr.,  1889,  Nr.  29  und  30)  has  asserted,  in  a  most  comprehensive 
report  on  this  affection,  that  the  abnormally  rapid  evacuation  of  the 
stomach  is  the  cause  of  bulimia.  This  would  naturally  include 
that  bulimia  is  very  frequent  with  pyloric  insufficiency,  in  which,  as 
we  know,  the  ingesta  at  once  enter  the  intestine  from  the  stomach. 
Bulimia  should  also  then  be  frequent  in  cases  where  a  gastro- 
enterostomy has  been  executed  for  benign  stenosis  of  the  pylorus. 
Ewald  and  Fleischer  have  reported  cases  of  bulimia  in  which  there 
was  no  hypermotility.  The  combination  of  bulimia  with  hyper- 
motility  may  possibly  be  explained  by  the  fact  that  intense  exci- 
tation of  the  hunger  center  may  extend  to  neighboring  centers  in 
the  medulla,  and  involve  even  the  vagus  center,  which  responds  by 
affecting  a  more  rapid  evacuation  of  the  gastric  contents  into  the 
intestines.  Some  of  the  accompanying  symptoms  of  bulimia  (tin- 
nitus, and  roaring  in  the  ears,  palpitation  of  the  heart,  and  fainting) 
are  attributed  by  R.  Ewald  (the  physiologist)  to  secondary  irri- 
tation of  nervous  centers  lying  in  close  proximity  to  the  hunger 
center.  The  affection  expresses  itself  by  violent  sensations  of 
hunger  coming  on  suddenly,  even  shortly  after  the  completion  of 
a  full  meal,  and  if  the  desire  for  food  is  not  immediately  gratified, 
the  patients  exhibit  signs  of  fright,  weakness,  headache,  pallor  of 
the  face,  palpitation  of  the  heart,  roaring  noises  in  the  ears,  and 
gastric  distress.  The  attacks  may  sometimes  occur  periodically, 
46 


702  SENSORY    NEUROSES. 

but,  as  a  rule,  occur  irregularly.  In  the  intervals  between  the 
attacks,  hunger  and  appetite  are  normal.  According  to  Boas, 
bulimia  may  alternate  with  anorexia. 

Causation. — Bulimia  maybe  an  idiopathic,  central  neurosis  con- 
nected with  abnormal  irritability  of  the  hunger  center,  or  a  symp- 
tomatic affection  which  Leo  {loc.  cit}j  has  observed  in  exophthalmic 
goiter,  with  gastric  ulcer  and  hyperacidity,  chronic  gastritis,  tape- 
worm, diarrhea,  and  menorrhagia.  It  has  been  observed  even  with 
carcinoma  and  dilatation.  Fleischer  states,  without  reserve,  that 
the  hyperexcitability  of  the  hunger  center  is  not  caused  by  sudden 
and  excessive  impoverishment  of  the  blood  in  nutritive  substances, 
because  the  attacks  may  occur  immediately  after  an  abundantly 
nutritious  meal  which  has  brought  about  a  feeling  of  satiety,  and 
because,  in  other  cases,  the  morbid  sensation  may  be  relieved  by  a 
mouthful  of  bread  or  a  swallow  of  beer  or  wine.  The  fact  that 
the  sensations  of  hunger  and  thirst  are  normal  in  the  intervals 
between  the  attacks,  or  even  at  times  entirely  absent,  argues 
against  the  assumption  that  bulimia  is  always  caused  from  a  con- 
dition of  the  blood  acting  upon  the  central  nervous  system.  The 
following  are  morbid  conditions  in  which  bulimia  has  been 
observed  to  occur :  Cerebral  tumors,  epilepsy,  psychoses,  hysteria 
and  neurasthenia,  focal  diseases  of  the  brain,  cerebral  concussion, 
Basedow's  disease,  Addison's  disease,  tuberculosis,  syphilis  (accord- 
ing to  Fournier,  Gazette  Hebdoui.,  1871,  Nos.  1—3,  it  occurs 
between  the  third  and  sixth  month  of  this  disease),  diabetes 
mellitus,  uterine  disease,  chronic  gastritis,  ulcer,  dilatation,  car- 
cinoma, enteritis,  and  intestinal  parasites.  Bulimia  has  also  been 
observed  during  the  puerperium.  Some  authors  classify  the 
ravenous  appetite  following  exhaustive  continued  fevers,  as  well  as 
that  following  abundant  loss  of  blood,  with  bulimia.  This,  in  our 
opinion,  is  not  a  justifiable  classification,  because  the  increase  of 
hunger  in  these  cases  can  be  explained  in  a  simple  and  natural  way 
without  assuming  a  hypothetical  excitability  of  the  hunger  center. 
In  diabetes  mellitus  we  may  assume  the  existence  of  an  abnormal 
irritability  of  the  hunger  center  because  these  patients  are  not 
satisfied  even  shortly  after  large  meals.  It  has  been  supposed  that 
the  glucose  circulating  m  the  blood  is  the  agent  that  causes  this 
irritation  of  the  hunger  center.  In  diabetic  patients  in  which  the 
sugar  in  the  blood  and  urine  has  been  reduced  by  a  diet  limited 
exclusively  to  fat  and  albuminous  food,  the  torturing  feelings  of 


SYMPTOMS    OF    BULIMIA.  703 

hunger  disappear,  to  return  again  if  the  mellituria  is  allowed  to 
increase  on  other  diet.  According  to  Pettencofer  and  Voit,  the 
metabolism  of  diabetic  patients  is  much  increased  ;  which,  of  course, 
means  a  more  rapid  consumption  of  the  nutritive  elements  of  the 
blood.  The  impoverishment  of  the  blood  is  further  augmented  by 
the  fact  that  the  sugar  which  is  formed  from  the  amylaceous 
substances  of  the  food  is  only  partially  or  not  at  all  utilized  in  the 
economy.  The  diagnosis  of  bulimia  should  only  be  made  in 
diabetes  if  the  violent  sensations  of  hunger  continue  notwith- 
standing very  rich  and  very  abundant  meals,  or  if  it  recurs  very 
soon  after  such  meals,  by  which  the  blood  must  have  been  charged 
with  nutritive  substances  for  a  longer  time.  Ewald  and  Boas  have 
observed  that  the  attacks  grow  less  after  bodily  exercise  in  the 
open  air.  According  to  Rosenthal,  the  affection  is  more  frequent 
in  women  than  in  men,  and  occurs  most  often  between  the  twentieth 
and  fortieth  year. 

Symptomatology. — The  main  and  most  characteristic  symptom 
is  the  impulsive  sensation  of  hunger,  which  by  any  and  every 
means  commands  the  ingestion  of  food.  The  pallor,  weakness, 
and  terror,  with  attacks  of  fainting  and  roaring  in  the  ears,  we  have 
already  described.  This  sensation  comes  on  generally  within  one 
to  two  hours  after  meals,  or  it  may  occur  within  ten  minutes  after 
meals.  We  have  known  several  old  gentlemen  who  were  for  a  long 
time  aroused  in  the  middle  of  the  night  by  this  torturing  sensation 
of  hunger.  Some  patients  complain  of  gnawing  and  boring  pain  if 
the  hunger  is  not  gratified.  Very  small  quantities  of  milk,  beer,  or 
wine,  or  only  a  few  mouthfuls  of  cracker  or  bread,  Avill  cause  the 
entire  train  of  symptoms  to  disappear.  Peyer  {Correspondenzbl. 
Schweitzer  Aerzte,  1888,  Nr.  20)  reports  a  case  of  a  paroxysm  of 
bulimia  occurring  in  a  female  patient  when  she  was  away  from 
home  visiting  a  friend.  The  weakness  ensuing  is  described  as 
being  so  great  that  she  could  not  return  home.  Peyer  asserts  that 
in  three-quarters  of  an  hour  she  consumed  three  pints  of  milk,  23 
eggs,  and  two  pints  of  strong  wine  before  the  bulimia  and  pain  in 
the  stomach  ceased.  The  patient  then  fell  asleep,  and  returned 
home*  perfectly  well  on  awakening.  Potton  reports  the  case  of  a 
young,  hysterical  girl  who  was  obliged  to  take  11  or  12  meals  a 
day,  and  even  eat  during  the  night ;  she  is  claimed  to  have  ingested 
between   10  and  12  kilograms  per  diem,  and  was  finally  cured  by 


704  SENSORY    NEUROSES. 

gradually-increasing  doses  of  morphin.       This  was  a  case  of  so- 
called  continued  bulimia. 

Diagnosis. — Wherev^er  the  abnormal  sensation  of  hunger  oc- 
curs shortly  after  abundant  food  has  been  taken,  the  diagnosis  is 
not  difficult ;  at  other  times  it  may  be  confounded  with  polyphagia 
and  acoria.  In  polyphagia,  the  desire  for  eating  is  very  much 
increased,  but  it  does  not  occur  until  some  time  after  the  meals, 
and  occurs  gradually,  not  developing  the  intense  hunger  suddenly. 
So,  polyphagia  is  simple  increase  of  the  normal  sensation  of  appe- 
tite, such  as  we  find  in  diabetes  mellitus.  It  is  impossible  to  strictly 
separate  polyphagia  from  bulimia — both  occur  under  similar  condi- 
tions and  as  primary  or  secondary  neuroses.  Bouveret  ("  Traite 
des  Maladies  de  I'Estomac,"  Paris,  1893,  page  654)  refers  to  a  case 
in  which  a  patient  seventeen  years  old  could  devour  100  pounds  of 
meat  in  twenty-four  hours,  and  Rosenthal  reports  an  instance  of  a 
woman,  aged  twenty-eight  years,  who  ate  at  one  meal  a  whole  roast 
of  goose  and  a  large  portion  of  bread.  There  is  a  so-called  con- 
tinued form  of  bulimia  which  alternates  with  acoria,  or  the  absence 
of  the  feeling  of  gratification  or  satisfaction  after  meals.  If  it  can 
be  found  that  the  feeling  of  hunger  is  very  great,  and  even  continues 
or  returns  after  abundant  meals,  then  we  are  dealing  with  bulimia; 
but  if  the  sensation  of  hunger  is  normal  or  reduced,  and  ceases 
after  larger  meals,  but  without  causing  the  feeling  of  satiety,  we 
are  dealing  with  acoria.  The  continued  form  of  bulimia  has  hith- 
erto been  found  only  with  diabetes  mellitus  and  hysteria.  We 
have  had  two  cases  in  hospital  practice  which  illustrate  that  bulimia 
and  polyphagia  may  be  developed  by  practice.  Both  cases 
occurred  in  negroes  who  had,  as  a  result  of  a  number  of  wagers, 
eaten  large  quantities  of  food.  One  colored  man  was  a  waiter  at  a 
hotel  at  Cape  May,  N.  J.,  and  used  to  exhibit  himself  in  eating  a  huge 
watermelon  together  with  eight  pies.  The  other  negro,  who  was  a 
patient  at  Baltimore,  gradually  developed  his  polyphagia  from  par- 
ticipating in  rival  encounters  with  other  individuals  of  his  race  to  see 
who  could  eat  the  most  oysters.  It  is  claimed  that  this  man  could 
eat  three  quarts  of  oysters,  with  a  large  amount  of  crackers  and  beer. 
Both  negroes  found  later  that  the  habit  had  developed  into  a  dis- 
ease, the  tremendous  appetite  developing  very  often  within  a  half 
hour  after  the  big  meals  of  bread,  fish,  and  egg  had  been  taken. 
One  of  them  has  been  cured  by  dram  doses  of  bromid  of  ammo- 


NATURE    OF    ACORIA.  705 

nia  four  times  daily.  The  diagnosis  of  an  affection  of  this  character 
can  not  be  stated  in  such  exact  terms  as  that  of  an  organic  disease, 
as  individual  opinions  of  specialists  as  to  what  really  constitutes 
bulimia  will  probably  vary  greatly.  (The  treatment  will  be  con- 
sidered together  with  that  of  acoria.) 


ACORIA. 

This  word  is  derived  from  «  and  yopiwuiu^ — I  become  satiated. 

Absence  of  the  normal  feeling  of  satiation,  even  after  very 
abundant  meals,  without  increase  of  hunger  or  appetite. 

Acoria  is  not  identical  with  bulimia  or  polyphagia,  for  in  both 
of  these  there  is  a  very  strong  feeling  of  hunger,  while  in  acoria 
we  may  have  absence  of  appetite.  Even  in  polyphagic  gluttons 
the  feeling  of  satiation  will  eventually  supervene,  but  not  in  acoria. 
The  disease  is  generally  secondary  to  neurasthenia,  hysteria,  and 
certain  psychoses.  It  is  occasionally  met  with  in  sexual  neuras- 
thenics. The  feeling  of  satiation  is  no  positive  sensation  ;  it  occurs 
when  hunger  and  appetite  have  been  appeased,  and  is  therefore 
a  negative  sensation.  Hunger  and  appetite  cease  normally  when 
the  hunger  center  passes  from  a  sensation  of  excitation  to  that 
of  rest.  The  amount  of  food  required  to  accomplish  this  varies 
greatly  in  different  persons,  and  even  in  the  same  person  at  different 
times.  One  hypothesis  has  attempted  to  explain  acoria  on  the 
basis  of  overexcitation  of  the  hunger  center.  If  this  were  the 
case,  we  would  find,  periodically  at  least,  an  increased  sensation  of 
hunger  after  large  meals  which  is  never  observed  in  acoria,  for 
hunger  and  appetite  are  normal,  or  even  subnormal,  in  acoria. 
Some  patients  even  state  that  after  meals  hunger  ceases,  but  they 
have  no  feeling  of  satiation  ;  in  fact,  no  impression  whatever  from  the 
stomach  informing  them  that  they  have  eaten  enough.  It  is  well 
known  that  many  people  are  not  satisfied  to  introduce  food  until 
the  appetite  has  been  appeased,  but  they  continue  long  enough 
to  perceive  a  feeling  of  pressure  and  slight  fullness  in  the  stomach, 
which  is  a  result  of  a  moderate  distention  of  the  gastric  walls 
by  ingesta.  While  moderate  eaters  perceive  this  sensation  as 
uncomfortable  and  indicating  supersatiation,  gormandizers  gradu- 
ally become  accustomed  to  this  feeling  of  pressure  and  fullness, 
sometimes  from  early  childhood,  so  that  eventually  they  do  not 
believe  themselves   satiated   before  this  distention  occurs,  and  this 


706  SENSORY    NEUROSES. 

fullness  and  distention  is  finally  confounded  with  the  normal  sen- 
sation   of  satiety. 

The  next  step  in  the  development  of  this  nervous  anomaly  is 
that  the  feeling  of  pressure  and  fullness  may  mimic  a  temporary 
normal  feeling  of  satiation,  while  at  the  same  time  the  excitation 
of  the  hunger  center  continues.  The  sensation  of  hunger,  when 
it  is  not  very  strong,  may  be  in  some  cases  removed  by  filling  the 
stomach  with  perfectly  indigestible  material,  such  as  leaves  and 
sawdust.  In  the  voyage  of  the  Jeanette  (Journal  of  Lieutenant 
de  Long  commanding  the  expedition,  1883),  the  crew  of  the  sur- 
viving members  subsisted  upon  scraps  of  deer  skin,  which,  from  its 
bulk  in  the  stomach,  seemed  to  afford  relief  from  hunger.  After 
everything  was  exhausted  they  lived  upon  an  infusion  made  from 
arctic  willow,  containing  really  no  nourishment,  and  ate  two  old 
boots.  As  the  feeling  of  satiation  is  absent  after  copious  filling  of 
the  stomach  with  food,  and  as  it  can  not  be  disguised  by  an 
abnormal  feeling  of  hunger,  because  hunger  is  normal  or  sub- 
normal in  acoria,  another  explanation  that  has  been  offered  for 
this  nervous  affliction  is  that  it  is  due  to  loss  of  sensibility,  or 
anesthesia,  of  the  gastric  sensory  nerves.  This  seems  to  be  a  very 
probable  explanation,  since  we  have  personally  had  at  least  one 
experience  that  would  suggest  a  local  gastric  anesthesia  as  in  ex- 
planation of  acoria.  The  case  we  have  in  mind  is  that  of  a  young 
lady  whose  stomach  we  had  sprayed  with  a  three  per  cent,  solu- 
tion of  cocain  and  menthol.  She  returned  on  the  same  day,  stating 
that,  although  she  had  taken  a  long  bicycle  ride  after  the  spraying, 
and  returned  home  feeling  quite  hungry,  she  had  the  impression 
that  the  food  she  ate  never  reached  the  stomach.  She  had  no  feel- 
ing in  her  stomach  that  the  meal  effected  satiation.  At  first  we 
overlooked  the  causal  relation  between  the  spraying  with  menthol 
and  cocain  for  this  temporary  acoria,  and  our  attention  was  attracted 
to  it  after  the  same  symptoms  were  complained  of  each  time  the 
menthol  and  cocain  were  used.  These  agents  had  been  employed 
for  the  relief  of  gastralgic  pains  resulting  from  erosions.  The 
case  ultimately  recovered  by  treating  it  with  suspensions  of  sub- 
nitrate  of  bismuth.  It  is  conceivable  that  anesthesia  of  the  stom- 
ach nerves  may  occur  from  repeated  overdistention,  as  occur?  in 
bulimia,  polyphagia,  diabetes  mellitus,  and  dilatation  of  the  stomach. 

Symptomatology. — As  the  only  symptom  is  the  absence  of 
satiation,  the  clinical  picture  is  not  very  manifold.    The  complaints 


TREATMENT  OF  BULIMIA  AND  ACORIA.  JOJ 

of  the  patients  are  limited  to  the  statement  that  large  meals  cause 
no  sensation  of  having  had  enough  to  eat,  and  that  they  do  not 
know  when  to  cease  eating;  that  they  have  to  measure  out  their 
food  previous  to  beginning  to  eat,  in  order  to  know  when  they 
have  sufficient.  Some  of  these  patients  try  to  compel  a  feeling  of 
satiation  by  the  ingestion  of  enormous  quantities  of  food  and 
drink.  This  has  been  reported  as  a  cause  of  gastritis,  atony,  and 
dilatation.  The  prognosis  varies  according  to  the  fundamental 
disease.  The  diagnosis  is  made  from  the  single  important  symptom 
and  the  exclusion  of  bulimia  and  polyphagia.  Sometimes  we  find 
transitions  from  acoria  to  bulimia,  which  Boas  explains  by  a  reac- 
tive hyperesthesia  following  an  anesthesia  of  the  gastric  nerves. 
Acoria  is  distinguished  from  polyphagia  by  the  increased  desire  for 
food,  which  ismarked  in  the  latter,  very  likely  as  a  result  of  increased 
oxydation,  while  the  diagnosis  from  bulimia  hinges  upon  the  raven- 
ous desire  for  food  in  the  latter;  in  both  the  feeling  of  satiation  will 
eventually  supervene. 

Treatment. — The  treatment  of  bulimia  when  it  is  a  secondary 
disease  must  have  regard  for  removal  of  the  primary  cause,  such  as 
intestinal  parasites,  genito-urinary  diseases,  hyperacidity,  or  ulcer, 
and  any  existing  neurasthenia,  hysteria,  or  psychosis.  The 
bromids  are  very  valuable  remedies  to  reduce  the  irritability  of  the 
hunger  center;  they  should  be  given  in  the  form  of  bromid  of 
ammonia,  or  strontium,  30  gr.  of  either  four  times  a  day,  preferably 
in  peppermint  water.  The  following  formula  will  be  found  useful 
in  bulimia  : 

R.      Tinct.  opii  camph., 81.0  f^iij 

Tinct.  belladonnte, I.o  gtt.  xl 

Elix.  simplic, q.  s.  iSo.o  f^vj.     M. 

SiG. — One-half  of  a  fluidounce  three  times  a  day. 

Arsenic  in  form  of  Fowler's  solution,  beginning  with  three  to  five 
drops,  and  gradually  increasing  the  dose  to  10  to  15  drops,  is  highly 
recommended  by  Boas.  Rosenthal  recommends  subcutaneous  in- 
jections of  extract  of  opium,  and  has  seen  good  results  in  bulimia 
from  cocain  hydrochlorate.  Morphin  is  a  remedy  that  has  been 
followed  by  good  results  in  this  affection.  An  attempt  should  be 
made  with  the  use  of  electricity.  In  one  of  the  colored  patients 
to  whom  we  referred  as  champion  gluttons,  and  who  had  sub- 
sequently developed  bulimia,  the  symptoms  improved  very  much 


yo8  SENSORY    NEUROSES. 

under  the  intragastric  use  of  the  constant  current.  The  treatment 
of  acoria  should  be  mainly  that  of  neurasthenia;  climatic  changes 
and  electrical  hydropathic  cures  are  most  effective.  Intragastric 
douches,  with  alternating  warm  and  cold  water,  have  been  re- 
commended. It  is  very  important  that  these  patients  should  be 
watched  by  healthy  friends  during  their  eating ;  thorough  masti- 
cation and  insalivation  should  be  insisted  upon.  Strychnin  and 
massage  of  the  stomach  suggest  themselves  as  rational  means  of 
treatment. 

NERVOUS  ANOREXIA. 
By  anorexia  is  meant  an  entire  absence  of  appetite  and  loss  of 
the  sensation  of  hunger.  The  superlative  degree  of  this  sensation 
is  expressed  in  the  disgust  and  repugnance  toward  all  food.  There 
are  probably  no  pathological  conditions,  neither  of  the  stomach  nor 
of  any  other  organ  of  the  body,  in  which  anorexia  is  not  occasionally 
met  with.  In  most  anatomical  diseases  of  the  stomach  anorexia  is 
a  regular  accompaniment.  The  separation  of  appetite  and  hunger 
is  not  as  clear  as  one  might  presume  ;  the  two  are  not  necessarily 
synonymous,  nor  does  one  include  the  other.  Penzoldt  defines 
hunger  as  the  warning  or  admonition,  and  appetite  as  the  pleasure 
of  eating  (Bibliothek  der  ges.  medizin.  Wissenschaften,  heraus- 
gegeben  von  Drasche  :  article  on  "  Anorexia  ").  There  may  even  be 
appetite  when  there  can  not  possibly  be  hunger.  We  have  already 
spoken  of  the  various  forms  of  anorexia  that  may  accompany  the 
organic  and  functional  diseases  of  the  stomach.  By  nervous  ano- 
rexia we  mean  loss  of  appetite,  and  even  repugnance  to  food,  that 
may  extend  over  weeks  and  months,  with  a  perfectly  intact  diges- 
tive apparatus;  this  affection  is  found  principally  in  women,  and  is 
based  upon  neurasthenia,  hysteria,  anemia,  chlorosis,  and  certain 
neuroses  of  the  stomach.  It  is  found  in  those  addicted  to  the 
excessive  use  of  alcohol  and  tobacco,  and  as  a  symptom  of  the 
morphin  habit.  It  is,  therefore,  not  a  disease  peculiar  to  itself, 
not  a  typical  morbid  entity,  but  rather  a  sequence.  Whether  or 
not  nervous  anorexia  may  be  an  independent  disease  of  central 
origin,  a  neurosis  connected  with  a  reduced  irritability  of  the  hun- 
ger center,  has,  up  to  the  present  time,  not  been  satisfactorily 
investigated.  The  course  and  the  prognosis  depends  upon  the 
degree  of  the  repugnance  for  food.  Among  the  insane  and  very 
neurasthenic  patients  fatal  cases  have  been  reported. 


TREATMENT    OF    ANOREXIA.  7O9 

Symptomatology. — The  patients  who,  from  loss  of  appetite  or 
distress,  can  not  take  food,  grow  anemic  and  weak,  look  very 
emaciated,  have  a  slow,  feeble  pulse,  cold  hands  and  feet,  and  may 
even  give  the  impression  of  tuberculous  patients.  Rosenthal 
("  Magenneurosen,"  etc.,  Vienna  and  Leipzig,  1886),  Gull  (Tlie 
Lancet,  1868),  and  Charcot  ("  Oeuvres  Completes,"  tome  iii,p.  240) 
have  reported  fatal  cases  of  nervous  anorexia.  Insomnia  is  a  frequent 
symptom  of  this  affection.  Very  slight  anatomical  changes  in  the 
stomach  may  cause  anorexia  ;  it  is,  therefore,  almost  impossible  to 
make  the  diagnosis  of  secondary  or  primary  anorexia  with  precision. 

Diagnosis. — There  is  no  difficulty  about  the  diagnosis  of 
anorexia,  but  it  is  not  always  easy  to  discover  the  real  cause  of  it. 
We  will  find  under  the  consideration  of  enteroptosis  that  almost 
any  abdominal- organ  when  dislocated  may  produce  this  symptom. 
Organic  affections  of  the  stomach  must  be  excluded  before  we  can 
make  the  diagnosis  of  nervous  anorexia.  Very  frequently  chronic 
gastritis,  incipient  tuberculosis,  and  carcinoma  begin  with  this 
symptom  before  any  other  signs  or  symptoms  are  manifest. 

Treatment. — The  primary  object  of  the  treatment  must  be 
to  improve  the  general  nervous  condition,  to  correct  any  exist- 
ing fundamental  disease,  to  act  upon  the  psychic  sphere  by 
pursuasion,  suggestion,  and  firm  but  kind  argument,  and,  finally, 
to  combat  the  anorexia  itself  directly.  Any  existing  neuras- 
thenia and  hysteria  should  be  treated  by  methods  that  have 
been  spoken  of  repeatedly  for  these  affections.  Dujardin- 
Beaumetz  ("  Traitement  des  Maladies  de  I'Estomac,"  1891,  p. 
326)  speaks  very  highly  of  arsenic  in  the  treatment  of  nervous 
anorexia.  In  anemia,  mild  preparations  of  iron  (the  peptonates, 
albuminates,  ferratin)  are  almost  indispensable.  Dyspeptic  patients, 
as  a  rule,  do  not  tolerate  the  ordinary  preparations  of  iron, — the 
chlorid,  sulphate,  phosphate,  and  iodid  of  iron  ;  possibly  the  least 
irritating  of  these  to  sensitive  stomachs  is  the  chlorid.  In  order 
to  improve  the  general  nutrition,  the  Weir  Mitchell  rest-cure, — 
which  consists  in  isolating  the  patient  from  his  family  and  placing 
him  under  the  supervision  of  a  trained  nurse  and  experienced 
physician,  and  feeding  him  so  abundantly  that  gradually  a  gain 
of  weight  is  accomplished, — together  with  the  use  of  baths,  massage, 
and  electricity,  has,  in  many  cases  in  our  experience,  produced  happy 
results  when  other  means  have  failed.  Where  there  is  an  absolute 
repugnance  for  food,  or  where  the  patient  is  insane,  artificial  com- 


710  SENSORY    NEUROSES. 

pulsory  alimentation  by  gavage  should  not  be  postponed  too  long. 
We  have  considered  this  fully  on  page  182.  In  the  beginning  of 
the  trouble  the  bitter  tonics  are  available  to  stimulate  the  appetite. 
The  basic  orexin,  five  to  ten  grains,  three  times  a  day,  in  a  cup 
of  hot  bouillon,  produces  very  excellent  results  in  these  cases  of 
nervous  loss  of  appetite. 

Boas  speaks  very  highly  of  the  cinchona  bark.  It  may  be  pre- 
scribed in  the  following  formula  : 

R.      Tinct.  cinchonas  comp., 40.0         f,^  jss 

Acid,  sulphuric,  dil., 10. o         f;:^ij 

Syr.  zingiber.,  q.  s., 240.0         fo^j-     ^■ 

SiG. — One-half  of  a  fluidounce  in  two  ounces  of  water,  through  a  glass  tube,  three 
times  a  day. 

In  some  cases  in  which  the  anorexia  was  due  to  a  feeling  of 
pressure  and  discomfort  after  eating,  Rosenthal  reports  good  results 
from  10  to  15  grs.  of  bromid  of  sodium  given  before  meals.  Boas 
cautions  against  the  use  of  mineral  waters  in  the  treatment  of  this 
neurosis.  One  most  approved  combination  for  anorexia  is  given 
on  page  450;  it  contains  dilute  HCl,  because  we  have  found,  in  a 
very  large  number  of  cases  of  intense  nervous  anorexia,  that  the 
gastric  secretion  is  very  much  reduced  or  entirely  lost. 


CHAPTER  XI. 

NEUROSES    OF  SECRETION. 

HYPERCHYLIA  (Hyper-  or  Superaciditv,  Hyperchlorhydria). 

Most  digestive  pathologists  whose  clinical  and  laboratory  experi- 
ence renders  them  competent  to  judge,  consider  hyperacidity  and 
hypersecretion  of  the  gastric  juice  to  be  neuroses  of  the  secretory 
function.  They  are  regarded  as  functional  disturbances  of  the  nerves 
of  the  stomach,  which  may  occur  as  individual  diseases  or  as  part 
of  other  neurotic  conditions.  This  view  no  doubt  is  correct  in  a 
large  number  of  the  cases.  It  includes  the  opinion  that  in  this  dis- 
ease no  characteristic  changes  in  the  structure  of  the  gastric  mucous 
membrane  are  demonstrable.  Judging  from  the  results  of  Hayem, 
Cohnheim  and  Einhorn,  and  the  author,  which  we  have  already 
quoted  (pp.  130  to  135),  it  is  beyond  a  doubt  that  in  more  than 
one-half  the  cases  of  hyperacidity  examined,  proliferation  of  the 
glandular  elements  is  present. 

We  have  not  only  examined  fragments  of  mucosa  that  were  acci- 
dentally found  in  the  wash-water,  but  have  had  opportunities  of 
autopsies  on  cases  of  pronounced  and  prolonged  hyperacidity  that 
died  of  intercurrent  diseases.  In  serial  sections  of  these  stomachs 
it  was  found  that  the  prevailing  state  of  the  mucosa  was  that  of 
glandular  proliferation,  with  increase  in  the  number  of  oxyntic  cells. 
Such  stomachs  do  not  show  the  same  conditions  throughout.  On 
making  serial  sections  of  large  pieces  of  the  secretory  portion,  one 
occasionally  meets  with  areas  in  which  the  glandular  structure  is 
apparently  normal.  At  very  rare  intervals  one  can  even  find  sections 
showing  partial  glandular  atrophy.  This  is  so  rare  as  to  be  insig- 
nificant. Even  in  normal  stomachs  one  sometimes  finds  indications 
of  atrophy  in  serial  sections,  and  we  consider  that  these  changes 
are  very  limited,  and,  perhaps,  may  be  considered  as  processes 
of  reconstruction  and  transition,  where  accidentally  injured  or 
exhausted  glands  break  down  in  minute  foci  and  are  replaced 
gradually  by  newly-formed  gland-cells.     The  prevailing  condition, 

711 


712  NEUROSES    OF   SECRETION. 

then,  in  hyperacidity,  according  to  our  opinion,  is  proliferation  of 
the  glandular  elements. 

A  large  number  of  microscopical  investigations  will  be  neces- 
sary to  confirm  this  opinion.  We  have  thus  far  examined  the 
entire  stomach  of  four  cases  that  gave  the  clinical  picture  of  hyper- 
acidity before  death.  In  all  four  of  these  cases  the  proliferation  of 
the  glandular  elements  was  uniformly  present. 

Sir  William  Roberts  ("  Digestion  and  Diet,"  p.  240)  holds  that 
the  acid  in  what  he  calls  acid  dyspepsia  (which  seems  to  us  an  objec- 
tionable term,  since  it  does  not  define  which  of  the  diseases  that 
are  connected  Avith  excess  of  acidity  he  refers  to)  is  not  unmixed 
HCl,  but  that  lactic,  butyric,  tartaric,  and  malic  acids  are  present. 
These  are  probably  derived  from  salts  of  the  organic  acids  present 
in  articles  of  food  which  are  decomposed  by  the  HCl  of  the  gas- 
tric juice.  There  may,  of  course,  be  a  hyperacidity  due  to  organic 
acids,  which  may  present  all  the  symptoms  of  hyperchlorhydria;  at 
the  same  time  there  may  be  no  HCl  secreted  at  all.  What  we 
refer  to  clinically  as  hyperacidity,  however,  is  an  excessive  forma- 
tion of  hydrochloric  acid  from  the  gastric  glands.  Concerning  the 
nature  and  origin  of  this  acid  we  have  nothing  but  theories. 

It  has  been  suggested  that  the  hyperchlorhydria  is  due  to  an 
excess  of  chlorids  in  the  organism,  from  which  it  liberates  itself  by 
excretion  into  an  organ  where  the  freeing  of  the  system  from 
chlorids  could  at  the  same  time  become  of  utility  as  a  digestive 
secretion  in  the  form  of  HCl.  The  author  has  made  a  number  of 
experiments  by  feeding  carnivorous  animals  with  food  from  which 
the  chlorids  had  been  removed  so  far  as  was  possible.  The  acid- 
ity of  the  gastric  juice  of  the  dog  will  become  very  much  reduced 
if  the  chlorids  are  withdrawn  from  the  food.  This,  however,  is 
not  proof  of  the  fact  that  the  reduction  of  chlorids  is  the  cause  of 
the  diminished  secretion  of  HCl,  because  foods  containing  much 
chlorids  are  a  healthy  stimulant  to  the  normal  secretion  of  HCl, 
and  food  deprived  of  chlorids  can  not  exert  this  stimulation  upon 
the  mucosa.  Personally,  the  author  considers  it  very  probable  that 
hyperacidity  is  frequently  an  adaptive  process  ;  that  is  to  say,  the 
glandular  layer  gradually  develops  greater  secretory  powers, 
because  more  secretion  of  HCl  is  required  by  the  nature  of  the 
ingested  food.  We  have  been  told  by  physicians  practising  in 
Japan,  that  hyperacidity,  as  well  as  gastric  ulcer,  are  practically 
unknown  in  that  country,  which  may  be  partially  explained  by  the 


HYPERACIDITY    AN    ADAPTIVE    PROCESS.  /1 3 

exclusive  carbohydrate  diet  upon  which  the  middle  and  lower 
classes  of  that  nation  exist. 

It  is  a  well-known  fact  that  the  gastric  juice  of  carnivora  is  much 
stronger  in  HCl  than  that  of  the  herbivora.  It  may  not  be  so  well 
known  that  the  gastric  juice  of  a  carnivorous  animal  can  be  made 
to  contain  a  less  amount  of  HCl  by  being  fed  upon  a  carbohydrate 
diet  for  a  long  time.  Two  dogs  of  the  same  litter  (a),  fed  exclusively 
on  milk,  potatoes,  and  rye  bread,  and  (d)  fed  exclusively  on  beef, 
mutton,  pork,  fish,  and  water  :  At  the  end  of  one  year  dog  (a),  fed 
upon  carbohydrates,  had  a  gastric  juice,  one  hour  after  a  roll  and  a 
half  pint  of  water,  containing  3  per  icoo  of  HCl ;  dog  (d),  who  was 
fed  upon  a  meat  diet,  had  a  gastric  juice  containing  6.540  per  looo 
HCL  These  two  dogs  were  raised  in  two  entirely  different  families. 
Dog  (a)  was  raised  by  a  gentleman  living  in  a  country  district 
where  meat  was  not  easily  obtained  and  milk  was  very  abundant ; 
dog  (d)  was  raised  in  the  city,  and  lived  upon  the  refuse  meats  from 
the  table.  Unless  conducted  in  this  manner,  and  watched  by  com- 
petent observers  for  a  long  time, — at  least  one  year, — the  experi- 
ment is  of  no  practical  utility.  It  is  conceivable  that  we  do  not  as 
yet  know  all  of  the  constituents  of  the  gastric  juice  ;  clinically,  it 
has  been  very  frequently  observed  that  the  secretions  of  the  intes- 
tines may  contain  traces  of  products  of  metabolism  and  other 
toxins  when  the  function  of  the  kidney  is  suppressed  or  lost.  The 
gastric  juice  of  epileptics  may  contain  toxic  substances.  Augustini, 
who  recently  investigated  this  subject,  found  that  the  gastric  juice 
of  an  epileptic,  when  injected  into  the  abdomen  of  a  rabbit,  proved 
fatal,  with  general  toxic  symptoms  and  clonic  convulsions.  This 
was  especially  true  when  the  gastric  juice  was  obtained  immediately 
before  or  after  an  attack.  Normal  gastric  juice  was  found  to  produce 
no  such  evil  effects.  Augustini  concludes  from  these  experiments 
that  systematic  lavage  and  disinfection  of  the  stomach  and  intes- 
tines are  indicated  in  all  cases  of  epilepsy.  What  we  wish  to 
emphasize  in  this  introduction  to  the  consideration  of  hyperacidity 
is  that  hyperchlorhydria,  although  frequently  a  neurosis,  is,  in  our 
opinion,  very  often  a  process  of  adaptation  of  the  mucosa. 

Acidity  of  the  Urine  and  Gastric  Contents  in  the  Healthy 
and  the  Dyspeptic. — Mathieu  and  Treheux  [Arch.  Gen.  de  Med., 
November,  1895)  have  made  researches  on  this  subject.  They 
examined  the  urines  hourly  during  the  afternoon,  after  the  midday 
meal,  carrying  out  their  investigations  on  12  persons,  after  84  differ- 


714  NEUROSES  OF  SECRETION. 

ent  meals,  thus  making  over  400  estimates  of  the  degree  of  acidity 
of  the  gastric  contents  and  urine.  The  individuals  examined  were 
the  subjects  of  hyperchlorhydria,  with  and  without  symptoms  of 
gastric  dilatation,  carcinoma,  etc.  The  authors  conclude  that:  (i) 
There  is  a  relation  between  the  acidity  of  the  gastric  contents  and 
the  urine.  (2)  The  greater  the  production  of  acid,  whether  by 
secretion  or  fermentation,  the  greater  the  amount  of  acid  excretion  in 
the  urine.  (3)  Normally,  the  acidity  of  the  urine  falls  during  the 
first  three  to  five  hours  after  eating,  thereafter  it  increases.  (4)  Most 
often  there  is  an  almost  absolute  parallelism  between  the  two  curves 
of  gastric  and  urinary  acidity,  but  this  is  destroyed  after  a  repast 
by  the  presence  of  polyuria.  (5)  If  the  acid  is  withdrawn  by  any 
means  from  the  stomach,  the  amount  in  the  urine  falls  also,  and 
the  latter  may  even  become  alkaline.  (6)  The  average  quantity 
eliminated  by  the  urine  hourly  is  greater  in  hypochlorhydria  (sub- 
acidity)  than  in  hyperchlorhydria  (hyperacidity).  (7)  Milk  increases 
the  acid  in  the  urine,  owing  to  its  giving  rise  to  lactic  acid  in  the 
stomach.  (8)  It  is  not  possible,  at  any  rate  at  present,  to  trace 
the  curves  of  urinary  acidity  so  as  to  bear  indirectly  on  the 
question  of  the  chemical  variety  of  the  dyspepsia.  (9)  Milk  must 
be  excluded  from  test-meals  when  these  curves  are  to  be  studied. 
(10)  Patients  should  be  subjected  to  a  constant  regimen  for  some 
time  before  the  investigations. 

Nature  and  Concept. — As  the  name  implies,  the  factor  with 
which  we  are  most  particularly  concerned  in  this  neurosis  is  the  HCl. 
With  superacidity,  a  gastric  juice  unusually  rich  in  HCl  and 
pepsin  is  secreted  in  very  large  quantities  during  digestion,  as  a 
result  of  the  stimulation  of  the  foods.  On  this  account  free 
HCl  may  be  proved  in  the  stomach  after  test-meals  much  earlier 
than  under  normal  circumstances,  and  the  acidity  of  the  digestive 
mixture  is  further  increased  as  digestion  proceeds.  Superacidity 
may  be  an  independent  disease  confined  to  the  stomach  alone, 
or  a  partial  symptom  of  hysteria,  neurasthenia,  and  melancholia. 
It  may  also  be  noticed  as  a  reflex  neurosis  with  renal  calculus 
and  hepatic  colic,  and  as  the  companion  of  organic  changes  of 
the  stomach  (ulcus  ventriculi,  gastritis  acida). 

Historical. — Even  if  superacidity,  like  supersecretion,  has  been 
demonstrated  with  certainty  only  in  the  last  twelve  years,  through 
the  researches  of  Reichmann,  Jaworski,  van  den  Velden,  Riegel,  the 
latter's  pupils,  and  others,  and  the  aspect  of  the  disease  has  been 


HISTORICAL    FACTS    ON    HYPERACIDITY.  /1 5 

precisely  defined  by  them,  nevertheless,  as  Ewald  justly  emphasizes, 
it  would  be  an  error  to  believe  that  we  have  to  do  with  an  entirely 
new  discovery,  since  both  these  anomalies  of  secretion,  as  also 
their  nervous  origin,  were  known  to  older  physicians  in  the  begin- 
ning and  middle  of  this  century, — men  celebrated  in  England, 
France,  and  Germany  (Trousseau,  Todd,  Budd,  Copland,  Pemberton, 
Hiibner,  and  others).  By  some  of  these,  the  most  important  symp- 
toms were  also  correctly  stated.  It  is  not  intended  that  the  merit 
of  the  previously-mentioned  investigators  of  these  neuroses  of 
secretion  shall  be  in  any  way  diminished  by  this  older  historical 
reminiscence,  for  as  the  older  physicians,  owing  to  the  lack  of 
exact  methods,  could  not  recognize  those  anomalies  of  secretion 
with  certainty,  their  results  were  soon  forgotten  ;  Reichmann  was 
the  first  who,  by  a  thorough  examination  of  the  contents  of  the 
stomach,  with  the  help  of  newer  and  constantly-improving  methods, 
furnished  certain  proof  of  the  existence  of  secretory  disorders  which 
had  previously  been  only  suspected,  while  it  was  Ewald  especially 
who  emphasized  particularly  the  nervous  origin  of  supersecretion 
and  superacidity,  so  that  soon  they  were  generally  recognized  as 
neuroses.  The  observations  of  Reichmann  were  soon  after  con- 
firmed by  von  Noorden,  Honigmann,  Riegel,  Jaworski,  Saly,  and 
others,  and  to-day  there  is  a  consensus  of  opinion  concerning  the 
nature  and  consequences  of  both  neuroses.  Jaworski  designates 
both  neuroses  as  very  frequent  disorders,  since  he  could  prove  them 
in  almost  two-thirds  of  his  patients  who  had  diseases  of  the 
stomach,  while  Riegel  also  observed  them  very  frequently  in 
Hessia — although  not  quite  so  frequently  as  Jaworski — Ewald, 
with  whom  the  author  can  agree,  states  that  they,  especially  super- 
secretion,  occurred  only  in  a  fraction  of  his  patients  with  diseases  of 
the  stomach,  so  that  supersecretion  should  be  called  rare,  rather 
than  frequent. 

Etiology. — The  fundamental  causes  of  superacidity  are  still 
unknown.  The  little  that  has  up  to  date  become  known  con- 
cerning the  etiology  of  the  disease  is  confined  to  the  knowledge  of 
a 'few  predisposing  factors.  Very  excitable  people,  predisposed  to 
nervous  disorders,  more  frequently  become  affected  with  super- 
acidity than  those  of  calm  temperament,  who  do  not  lose  their 
equanimity  so  easily,  although  it  is  not  found  entirely  wanting 
in  the  latter.  Jaworski  found  hyperacidity  very  frequently  in 
the  excitable  Jewish  population  of  Galicia,  pre-eminently  disposed 


yi6 


NEUROSES    OF   SECRETION. 


to  nervous  disorders.  With  hysterical  patients  superacidity  was 
noticed  by  Jolly,  and  in  melancholic  subjects  by  von  Noorden,  and 
it  is  also  a  frequent  companion  to  neurasthenia.  The  disease  is 
more  common  in  men  than  in  women.  The  educated,  and  particu- 
larly the  learned,  classes  furnish  the  main  body  of  patients  suffering 
from    hyperchylia,  though   it    is    not    infrequent  in  the    laboring 


Fig.  40. — Hypertrophy  and  Proliferation  of  Glandular  Elements. 
From  a  case  of  persistent  hyperacidity  found  in  the  eye  of  the  tube. 


classes.  Local  causes  seem  to  play  an  important  role  in  the  etiology 
of  hyperchylia,  and  this  is  vouched  for  by  the  frequent  occurrence 
of  the  disease  in  Galicia  and  Hessia  (Riegel),  while  it  is  much  rarer 
in  other  districts.  It  would  be  a  valuable  contribution  by  various 
gastro-enterologists  of  the  United  States  if  they  collected  and  re- 
ported the  frequency  of  hyperacidity  and  other  gastric  diseases 
occurring  in  their  localities,  so.  as  to  throw  lieht  on  the  influences 


SYMPTOMS    OF    HYPERACIDITY.  /I/ 

of  race,  climate,  geographical  distribution,  etc.  It  is  our  opinion 
that  a  diet  rich  in  fish,  meats,  and  proteids  in  general  predispose  to 
hyperacidity.  That  the  frequent  occurrence  of  superacidity  with 
cholelithiasis  and  nephrolithiasis  is  a  causal  relation  and  not  a  mere 
accidental  coincidence  is  shown  by  the  fact  that  the  stomach  com- 
plaints dependent  on  superacidity  generally  disappear  quickly  after 
the  passage  of  the  calculi  into  the  intestines  and  bladder  respectively. 
The  relation  between  superacidity  and  peptic  ulcer  has  been  suffi- 
ciently dwelt  upon  in  the  discussion  of  the  pathogenesis  of  the  latter  ; 
whether  superacidity  is  a  cause  or  result  of  the  ulcer,  it  has,  up  to 
date,  been  impossible  to  decide  with  certainty.  In  the  first  half  of 
this  work  the  author  has  laid  down  reasons  why  hyperchylia  may 
in  some  instances  be  sufficiently  explained  by  the  proliferation  of 
glandular  elements  observed  in  fragments  of  mucosa  found  in  the 
wash-water  in  one-half  to  two-thirds  of  the  cases  of  hyperacidity 
examined  (p.  135).  Whether  this  condition  is  the  cause  or  the 
result  of  the  neurasthenia  is  difficult  to  determine,  though  we  ob- 
served it  when  no  neurasthenia  could  be  detected. 

Symptomatology. — Disturbances  of  Sensibility. — The  subjective 
complaints  consist  chiefly  in  contracting,  boring,  burning,  or 
gnawing  pains  in  the  entire  region  of  the  stomach,  which  generally 
radiate  forward  or  toward  the  back.  As  they  are  the  consequences 
of  a  strong  irritation  of  the  mucous  membrane  of  the  stomach  by 
its  superacid  contents,  they  are  generally  only  noticed  during 
digestion,  appearing  some  time  after  eating,  and  generally  increasing 
perceptibly  with  the  progress  of  digestion.  They  are  much  influ- 
enced by  the  quantity  and  composition  of  the  food ;  with  meats 
they  are  much  less  than  with  an  amylaceous  diet.  After  the  intro- 
duction of  food  very  rich  in  albumin  they  appear  later  than  with 
a  diet  poor  in  albuminates,  mainly  because  in  the  former  case  the 
appearance  of  free  HCl  in  the  contents  of  the  stomach  is  post- 
poned. At  the  height  of  digestion  the  symptoms  are  generally 
most  severe.  Temporary,  strong,  cramp-like  pains  in  the  region 
of  the  pylorus  are  generally  the  result  of  a  spasm  of  the  muscular 
sphincter  of  the  pylorus.  By  alkalies,  as  also  by  the  renewed 
taking  of  milk,  eggs,  or  meat,  the  painful  sensations  are  generally 
soon  alleviated  or  temporarily  done  away  with,  so  long  as  the  acid 
is  held  in  combination  by  the  alkalies  or  albuminates.  If  a 
strong  generation  and  collection  of  gases  occur,  the  region  of 
the  stomach  is  swollen,  and  in  some  degree  sensitive  to  touch. 
47 


/1 8  NEUROSES    OF   SECRETION. 

If  the  escape  of  the  gases  upward  or  downward  is  temporarily 
prevented  by  simultaneous  cramp  of  the  cardia  and  pylorus,  the 
complaints  are  considerably  increased,  owing  to  the  strong  expan- 
sion of  the  walls  of  the  stomach.  Other  gastric  symptoms,  such  as 
nausea,  belching,  and  vomiting  of  very  acid  masses  accompany 
hyperchylia  very  frequently.  Belching  causes  slight,  passing 
relief,while  copious  vomiting  brings  greater  and  more  lasting  relief. 
If  small  quantities  of  the  very  acid  contents  of  the  stomach  are 
brought  up  through  the  eructations,  and  if  the  mucous  membrane 
of  the  esophagus  is  subjected  to  caustic  action  by  the  latter,  heart- 
burn develops,  which  may  increase  to  a  severe  contracting  pain 
under  the  breastbone,  which  extends  to  the  pharynx  (pyrosis 
hydrochlorica,  Sticker).  The  same  complaints,  naturally,  may  also 
appear  after  the  vomiting  of  the  contents  of  a  very  acid  stomach. 
The  manifold  subjective  symptoms  previously  stated  are  sometimes 
also  observed  with  neurasthenic  patients  in  whom  the  acidity  of 
the  gastric  juice  is  normal.  An  abnormal  sensibility  of  the  gastric 
nerves  to  hydrochloric  acid  must  be  supposed  in  these  cases 
(Talma).  The  appetite  is  generally  undisturbed  with  superchylia. 
Thirst  and  appetite  are  often  much  increased. 

TJie  Influence  of  HypercJiylia  Jipon  the  Transfoinnation  of  the  Foods 
in  the  Stomach. — As  is  well  known,  with  increasing  acidity  of  the 
gastric  juice  (at  least,  up  to  a  certain  limit)  its  digestive  power 
for  albuminous  foods  is  increased,  and  peptonization  proceeds 
more  quickly  and  freely  the  sooner  free  hydrochloric  acid  is 
present  in  the  contents  of  the  stomach.  Both  conditions  are 
given  with  patients  suffering  from  hyperacidity.  The  acidity  of 
the  gastric  juice  is  much  greater  than  that  of  the  normal  secretion, 
which  amounts  to  0.15  to  0.2  per  cent.  It  varies  between  0.3  and 
0.6  per  cent,  in  hyperchylia ;  in  severe  cases  between  0.4  and  0.6 
per  cent.,  so  that  in  these  80  to  120  c.c.  of  a  decinormal  solution 
of  caustic  soda  are  necessary  to  neutralize  10  c.c.  of  the  gastric 
contents  drawn  at  the  height  of  the  digestion  of  a  test-meal. 
Free  HCl  may  be  shown  in  the  contents  of  the  stomach  in  ten 
minutes  after  a  test-breakfast,  instead  of  in  an  hour,  and  in  one 
hour,  instead  of  in  three  to  four  hours,  after  the  full  test-dinner; 
therefore,  the  peptonization  of  albumin  proceeds  in  a  very  prompt 
and  free  manner.  On  the  other  hand,  gastric  amylolysis  is  much 
disturbed,  as  the  effectiveness  of  the  ptyalin  is  interrupted  very  early 
by  the  appearance  of  free  HCl.    On  this  account  one  finds,  in  three 


EFFECT    ON    PROTEOLYSIS AMYLOLYSIS    AND    PERISTALSIS.      Jig 

to  four  hours  after  an  experimental  meal,  no  undigested  mus- 
cular fibers  and  albuminous  particles  in  the  contents  of  the  stom- 
ach ;  but  many  unchanged  amylaceous  particles  may  still  be  found 
in  the  residue  on  the  filter.  (This  is  best  studied  with  the  double 
test-meal  as  recommended  on  p.  iii.) 

If  the  acidity  of  the  gastric  juice  exceeds  a  certain  maximum  (0.6 
to  0.7  per  cent,  and  over),  even  the  digestion  of  the  albumin  is  in 
some  way  retarded  (Schwann).  But  up  to  the  present  time  such 
great  quantities  of  free  HCl  have  not  been  met  with  in  the  contents 
of  the  stomachs  of  patients  suffering  with  hyperchylia. 

A  copious  formation  and  collection  of  gases  may  occur  in  this 
neurosis  of  secretion. 

The  Effect  on  the  Motor  Function. — With  very  severe  irritation 
of  the  mucous  membrane  of  the  stomach  by  the  overacid  contents, 
abnormally  severe  contractions  of  the  musculature  are  produced 
reflexly,  by  which  a  quicker  flow  of  blood  to  and  from  the  gastric 
walls  is  effected,  a  more  intimate  contact  of  the  ingesta  with  the 
mucous  membrane  of  stomach  hastens  the  secretion,  resorption, 
the  digestion  of  the  albuminates,  and  also  the  passing  over  of  the 
chyme  into  the  intestines.  Therefore  one  should  expect  a  quickened 
emptying  of  the  stomach  in  patients  with  hyperacidity  ;  but  in 
many  cases  exactly  the  opposite  is  noted;  namely,  a  retarded 
passage  of  the  contents  of  the  stomach  into  the  intestines.  It  is 
generally  caused  by  a  stubborn,  often-recurring  cramp  of  the 
pylorus,  brought  about  by  the  strong  irritation  of  the  mucous 
membrane  of  the  pylorus  by  HCl,  which  even  the  most  extreme 
contractions  of  the  rest  of  the  musculature  can  not  overcome. 
These  overexertions  of  the  latter  may  lead  to  fatigue  and  to 
atony,  and  the  appearance  of  this  state  is  furthered  by  the  fact 
that  the  coats  of  the  stomach  are  burdened  and  distended  by 
the  stagnating  ingesta  more  than  under  normal  circumstances. 
Since,  however,  the  musculature  can  rest  and  recuperate  with  an 
empty  stomach,  the  atony  does  not  very  frequently  pass  over 
into  a  chronic  state  of  dilatation  of  the  stomach.  The  formation 
of  the  dilatation  is,  however,  to  be  feared  when  the  cramp  of  the 
pylorus  brings  about  a  hypertrophy  of  its  ring  muscles,  and 
with  it  a  stenosis  of  its  lumen.  The  disturbances  of  circulation 
in  the  coats  of  the  stomach,  caused  by  the  cramp  of  the  pylorus, 
in  the  presence  of  a  very  acid  and  potent  gastric  juice  may 
favor   the  formation  of  peptic   ulcer.     The  troublesome   thirst  so 


720  NEUROSES    OF    SECRETION. 

often  complained  of  by  patients  was  formerly  explained  by  a  re- 
duction of  the  power  of  resorption  of  the  mucous  membrane, 
caused  by  the  strong  irritation  of  the  same  (HCl)and  spasm  of  the 
smaller  vessels.  The  quick  cessation  of  thirst  after  copious  drafts 
of  water  has  been  explained  by  the  dilution  of  the  acid  chyme  and 
a  decrease  of  the  irritation  of  the  mucous  membrane. 

That  superacidity  may  cause  disturbance  of  resorption  is  not 
to  be  denied.  Since  it  is  known,  however,  that  the  greater  part 
of  the  water  introduced  is  absorbed  only  in  the  intestine,  and  that 
the  resorption  of  water  in  the  normal  stomach  is  only  very  slight, 
it  might  be  more  correct  to  trace  back  the  thirst  with  superacidity 
to  the  cramp  of  the  pylorus  and  the  longer  retention  of  the  water 
in  the  stomach.  After  copious  drinking  of  water,  with  dilution  of 
the  contents  of  the  stomach,  the  irritation  of  the  mucous  mem- 
brane of  the  pylorus  decreases,  the  cramp  is  lessened,  and  the 
water,  passing  into  the  small  intestine,  is  then  quickly  reabsorbed  in 
the  latter.  That,  indeed,  a  cramp  of  the  pylorus  with  hyperacidity 
often  causes  retention  of  the  contents  of  the  stomach  may  be 
proven  by  the  introduction  of  the  tube  before  and  after  taking  the 
water — especially  when  it  contains  alkalies  (Saratoga  Vichy). 
Before  the  taking  of  water,  the  contents  of  the  stomach  still  show 
abundance  of  food,  while  some  time  after  the  stomach  is  generally 
found  to  be  entirely  empty. 

Urine. — After  copious  vomiting,  by  which  a  part  of  the  HCl  is 
permanently  removed  from  the  organism,  the  urine  has  an  alkaline 
or  neutral  reaction  (Sticker,  Gluzinski,  Jaworski,  and  Hiibner) ;  but 
this  may  be  observed  during  the  digestion  in  the  stomach  without 
vomiting.  Since  the  phosphates  more  easily  separate  out  of  the 
alkaline  urine,  it  may  happen  that  the  urine  is  turbid  when 
emptied  out  of  the  bladder,  a  circumstance  sometimes  unneces- 
sarily alarming  the  patient.  Or,  after  standing  a  while,  the  urine 
may  show  a  very  plentiful  sediment.  The  chlorids  are  sometimes 
decreased. 

The  state  of  nutrition  generally  remains  good,  especially  at  first. 
If  considerable  disturbance  of  the  motility  appears,  the  nutrition 
becomes  impaired. 

TJie  Digestion  of  the  Foods  in  the  Intestine. — If  the  contents  of  the 
stomach  enter  the  intestine  in  an  overacid  condition,  it  requires 
much  more  than  the  usual  time  to  attain  the  alkaline  reaction  in 
the  contents  of  the  intestines  with  the  help  of  the  mixed  alkaline 


DIAGNOSIS    OF    HYPERCHYLIA.  721 

intestinal  juices.  An  alkaline  medium  is  indispensable  for  the 
digestion  of  fats  and  carbohydrates. 

In  the  period  immediately  succeeding  the  passage  of  the  chyme 
into  the  small  intestine,  so  long  as  there  is  still  free  HCl  present 
a  small  part  of  the  undigested  albumin  is  peptonized  by  the  pepsin 
which  has  passed  over  along  with  it,  while,  on  the  other  hand,  the 
transformation  of  the  carbohydrates  and  fats  is  arrested  completely 
in  this  time. 

Consequently,  the  digestion  and  assimilation  of  the  foods  in  the 
intestine  are  much  retarded  in  severe  cases  of  hyperacidity,  and  the 
evacuation  of  the  bowels  is  correspondingly  delayed.  The  very 
acid  chyme  occasionally  produces  an  abnormally  intense  peristalsis 
of  the  intestine,  so  that  in  exceptional  cases  the  evacuation  of  the 
intestines  may  be  diarrheic  in  character. 

Prognosis. — This  is  favorable  if  the  disease  is  of  recent  origin; 
older  cases,  however,  are  often  stubborn.  The  ever-recurring  pains 
and  disturbances  of  digestion  may,  in  the  course  of  time,  wear  out  the 
patient.  With  symptomatic  superacidity  the  prognosis  must  be 
made  in  accordance  with  that  of  the  primary  complaints.  If  these — 
e.  g.,  hysteria,  neurasthenia,  melancholia,  peptic  ulcer,  or  cholelithi- 
asis and  nephrolithiasis — are  successfully  relieved,  the  superacidity 
will  quickly  disappear.  In  the  author's  experience,  permanent 
relief  may  follow  persistent  treatment,  even  in  chronic  cases. 

Diagnosis. — In  this  disease  our  double  test-meal  (see  p.  ill)  is 
a  special  diagnostic  aid.  If  a  strong  reaction  for  HCl  is  shown  in  the 
contents  of  the  stomach  after  ten  to  twenty  minutes  succeeding  the 
test-breakfast,  or  in  one  to  one  and  one-half  hours  after  the  test- 
dinner,  and  if  the  macroscopic  and  m.icroscopic  examinations  in  the 
residue  on  the  filter  still  show  abundant  remnants  of  carbohydrates, 
with  complete  absence  of  muscular  fibers  and  particles  of  albumin, 
then  the  diagnosis  of  hyperacidity  is  established,  even  though  the 
other  previously-mentioned  symptoms  may  be  absent.  In  order 
to  prove  or  disprove  a  co-existent  supersecretion,  we  recommend  to 
let  the  patient  take  the  test-meal  at  night,  and  the  next  morning 
introduce  the  tube  before  breakfast.  If  it  contains  large  quantities 
(over  lOO  c.c.)  of  a  potent  secretion,  then  supersecretion  exists  side 
by  side  with  superacidity ;  and  if  the  stomach  be  empty,  or  if 
only  a  small  quantity  of  gastric  juice  be  found  in  it,  then  superse- 
cretion is  not  present.  The  result  is  still  more  certain  if  a  few 
hours  after  the  last  evening  meal  the  stomach  is  thoroughly  washed 


722  NEUROSES    OF    SECRETION. 

out  and  the  next  morning  the  tube  is  introduced  into  the  jejune 
stomach.  Schreiber  asserts  that  supersecretion  is  found  only  in 
atonic  stomachs. 

The  differential  diagnosis  between  the  ulcer  and  hyperch\-lia  is 
of  practical  importance  on  account  of  the  therapeutics  to  be  fol- 
lowed. With  both  diseases,  the  manifold  subjective  complaints 
appear  usually  after  eating :  during  digestion,  with  peptic  ulcer 
patients,  generally  very  soon  after  eating  ;  with  those  suffering  from 
hyperchylia,  later  on  at  the  height  of  digestion,  though  the  onset 
varies  considerably  according  to  the  quantity  and  character  of  the 
foods. 

With  ulcer,  the  pains  are  generally  confined  to  one  region, 
namely,  the  epigastrium  (circumscribed  pain  caused  by  pressure), 
and  they  very  often  radiate  forward,  laterally,  toward  the  loins  and 
shoulder-blades  (dorsal  pain-points),  while  in  the  case  of  super- 
acidity  a  diffused  sensation  of  pain  exists  in  the  whole  region  of  the 
stomach  and  the  radiating  pains  are  wanting,  and  also  the  dorsal 
pain-points,  which,  in  the  case  of  ulcer,  will  be  present  in  about 
one-third  of  the  cases. 

In  the  case  of  ulcer  the  pains  are  generally  strongest  when  food 
in  itself  difficult  of  digestion  has  been  introduced  in  large  quanti- 
ties, and  it  is  irrelevant  in  this  case  if  the  food  consisted  mainly 
of  carbohydrates  or  meats;  in  the  case  of  hyperchylia  the  pains 
are  generally  less  severe  after  abundant  meals,  even  if  the  latter 
consisted  of  foods  in  themselves  difficult  of  digestion,  provided 
only  that  they  are  rich  in  albumin ;  after  smaller  m^eals  with  little 
albumin  the  pains  are  not  relieved. 

If  the  symptoms  observed  in  the  patient  do  not  suffice  to  estab- 
lish a  positive  differential  diagnosis  between  ulcer  and  hyperacidity, 
it  is  safer  to  treat  the  patient  for  ulcer, — this  may  be  the  case  when 
it  is  impossible  to  pass  the  tube  on  account  of  suspected  ulcer. 
If  the  pains  become  less  or  cease  entirely  soon  after  beginning 
this  treatment,  it  is  probably  a  case  of  ulcer,  while  if  they  remain 
the  same  or  increase  it  is  a  case  of  hyperacidity.  If  the  hyper- 
acidity is  removed  by  this  treatment  at  the  same  time  as  the 
ulcer,  this  fact  suggests  that  the  hyperchylia  was  not  the  cause, 
but  the  result,  of  ulcer.  On  the  other  hand,  if,  after  curing  the 
ulcer,  the  hyperchylia  continues,  we  may  presume  either  an  acci- 
dental coincidence  of  the  two,  or  else  the  hyperacidity  has  caused 
the  ulcer.     In   the   latter   case,  the  breaking   out   of  the   ulcer  or 


AMYLACEOUS    OR    PROTEID    DIET    IN    HYPERACIDITY.  723 

the  formation  of  new  ulcers  is  to  be  feared  in  the  future  should 
the  hyperacidity  continue. 

Therapeutics. — {a)  Diet. — The  selection  of  proper  diet  for  these 
cases  is  one  of  the  most  important  duties  of  the  general  practi- 
tioner and  specialist.  There  are  two  systems  of  dietetic  treatment 
for  hyperchylia.  One  favors  the  use  of  amylaceous  diet  and  the 
restriction  of  proteids,  because  the  latter  are  powerful  stimulants 
to  HCl  secretion.  The  advocates  of  the  other  argue  that,  since 
the  manifold  complaints  with  hyperchylia  are  a  result  of  the 
irritation  of  the  nerves  of  the  stomach  by  free  HCl,  therefore, 
in  the  fixing  of  a  rational  diet  such  foods  must  be  chosen 
which  combine  with  the  greatest  quantity  of  HCl ;  that  is,  in 
the  first  place,  meats ;  in  the  second,  vegetables  especially  rich  in 
albumin.  All  the  stimulants  which  might  further  increase  the 
irritation  of  the  nerves  of  the  stomach  must  be  avoided,  viz.^;^ — 
pungent  spices,  tapioca,  pepper,  also  mustard,  horse-radish,  ginger, 
organic  acids,  such  as  lactic,  acetic,  citric,  and  tartaric  acids,  fatty 
acids  (rancid  fat) ;  cooking  salt  must,  so  far  as  possible,  be  kept 
out  of  the  stomach;  drinks  rich  in  alcohol  are  just  as  injurious, — 
strong  beer,  heavy  wines,  but  especially  whisky  and  cognac. 
Food  and  drink  must  not  be  taken  too  cold  (not  under  eight 
to  ten  degrees,  io°  R.  to  12.5°  C.)  and  hot  too  hot  (not  over 
45°  R.  or  56°  C).  After  foods  in  themselves  difficult  of  digestion, 
the  complaints  are  not  stronger  if  they  contain  much  albumin 
than  after  easily  digestible  ones,  nevertheless  the  latter  are  to  be 
preferred,  and  careful  preparation  is  requisite  in  order  to  avoid  a 
mechanical  irritation  of  the  nerves  of  secretion.  A  diet  consisting 
only  of  carbohydrates  is,  in  our  experience,  not  injurious.  We  have 
exhaustively  stated  the  advisability  of  amylaceous  diet  in  hyper- 
acidity on  pages  187  to  189.  Pure  fats  are  allowed  in  the  same 
quantities  as  in  the  case  of  healthy  people.  As  sugar  does  no  harm 
in  the  case  of  most  patients,  such  baked  foods  (cakes)  are  to  be  per- 
mitted in  which,  by  a  long  process  of  baking  or  roasting,  a  part  of 
the  starch  has  been  dextrinized ;  that  is,  well-toasted  bread,  cakes, 
breadcrust  soaked  in  milk,  and  also  certain  dextrinized  flours  (Hor- 
lick's  food,  Kufeke's  flour,  and  others).  On  account  of  frequent 
disturbance  of  the  motility  large  quantities  of  water,  by  which 
the  muscularis  of  the  stomach  is  unusually  distended,  must  not  be 
introduced  at  one  time  ;  it  is  much  better  to  give  small  quantities 
frequently,  by  which   at  the   same   time   the   acid  contents  of  the 


724  NEUROSES    OF   SECRETION. 

stomach  are  diluted.  Burning  thirst  is  best  quenched  by  frequent 
imbibing  of  small  quantities  of  alkaline  mineral  waters  (Saratoga 
Vichy,  Geyser,  Capon  Springs,  Apollinaris  water,  Seltzer,  Giess- 
hiibler,  Fachinger  water),  which  are  rich  in  carbonic  acid,  as  the 
latter  is  not  only  soothing,  but  also  aids  resorption.  If  this  does 
not  suffice,  repeated  injections  of  water  into  the  rectum  must  be 
ordered. 

Since  the  percentage  of  albumin  of  the  various  foods,  and  hence 
also  their  valence  toward  HCl,  vary  remarkably,  a  table  of  all 
these  foods  is  given  on  page  239,  showing  how  much  hydrochloric 
acid  they  may  hold  in  combination  until  the  appearance  of  a  weak 
but  distinct  reaction  with  the  Baeyer-Gunzburg  reagent. 

In  the  two  columns,  those  foods  occupy  the  first  places  which 
combine  with  the  least  amount  of  HCl ;  those  which  combine  with 
the  greatest  amount  of  hydrochloric  acid  (meat,  poultry,  game, 
fish,  vegetables,  etc.)  stand  at  the  end  of  the  column. 

From  this  survey  it  appears  that  for  patients  with  hyperchylia, 
veal,  beef,  mutton,  and  raw  ham  (which  hold  in  combination  two 
to  three  times  as  much  HCl  as  the  same  quantities  of  sweetbread, 
liver  pudding,  and  calf's  brain)  are  to  be  recommended.  For  the 
same  reason  the  Leube- Rosenthal  meat  solution,  which  in  itself  is 
easily  digestible,  can  be  recommended.  Also  cooked  ham  and  pork 
are  suitable  meats.  Of  the  other  foods,  Swiss  cheese,  Roquefort,  pea 
sausage,  brick  cheese,  and  of  the  various  kinds  of  bread,  especially 
pumpernickel  and  rye  bread  are  available;  wheat  bread  is  not  so 
suitable,  as  700  gm.  of  it  are  necessary  to  combine  with  the  same 
quantity  of  HCl  which  is  held  in  combination  by  300  gm.  of 
pumpernickel  or  100  gm.  of  veal.  Beer  is  not  suitable.  Milk  is  to 
be  recommended,  however,  both  on  account  of  its  digestibility  and 
composition.  If,  on  account  of  muscular  disturbances,  it  is  desired 
to  avoid  large  quantities  of  liquids,  condensed  milk  should  be 
advised  ;  600  gm.  milk,  condensed  to  one-fourth  of  its  volume,  com- 
bines with  as  much  HCl  as  100  gm.  veal.  Cocoa  is  also  to  be 
recommended. 

If  gastric  distress  and  pain  appear  after  supper  before  bedtime, 
the  patient  should  drink  a  cup  of  lukewarm  milk,  bouillon  with 
Qgg,  and  meat  solution,  or  eat  raw  ham  scraped  fine,  or  one  egg, 
which  also  combines  with  a  great  deal  of  HCl  (see  p.  319). 

This  large  ingestion  of  proteid  and  albuminous  food,  espe- 
cially advocated  by  Fleischer  for  hyperacidity,  does   not   lead    to 


MEDICINAL    TREATMENT    OF    HYPERACIDITY.  725 

permanent  relief,  in  the  author's  experience.  According  to  care- 
fully conducted  experiments  and  analyses,  he  is  of  the  opinion 
that  a  proteid  diet  may  keep  up  a  hyperacidity  because  it  is  a 
stronger  stimulation  to  HCl  secretion  (see  p.  187). 

(^)  Medici7ial  Treatment. — We  refer  to  pages  322  to  326  in  ex- 
planation of  the  use  of  alkalies  in  hyperacidity.  Magnesia  is 
preferable  to  the  carbonates  because  it  can  not  form  chlorids, 
which  may  irritate  the  mucosa.  As  may  be  seen  from  the  table 
(p.  239),  the  albuminates  of  the  foods  may  take  up  considerable 
quantities  of  HCl  and  after  their  transformation  into  peptone  hydro- 
chlorate  they  aid  the  nutrition  of  the  body,  which  is  not  the  case 
with  the  chlorids.  The  digestive  products  of  albumin,  hemi- 
albuminose,  and  peptone,  combine  with  more  HCl  in  the  formation 
of  their  hydrochlorate  compounds  than  albumin  itself  (peptone 
almost  twice  the  amount),  and  the  peptonizing,  as  well  as  the 
decomposition,  of  the  peptone  hydrochlorate  in  the  blood  requires 
some  time,  so  that  the  HCl  combined  with  it  does  not  readily 
become  free  again. 

Some  of  the  alkalies  may  be  taken  in  the  form  of  alkaline  mineral 
water — Saratoga  Vichy,  St.  Louis  Spring  (Mich.),  Apollinaris, 
Biliner  Water,  Fachinger,  Salters,  Vichy  Water.  Magnesia  usta, 
bicarbonate  of  soda,  sodium  biborate  (Jaworski,  L.  Wolff),  are  best 
prescribed  as  indicated  on  page  325.  If  there  is  an  inclination  to 
the  formation  of  gases,  the  bicarbonate  of  soda  is  to  be  replaced  by 
magnesia  usta  in  order  not  to  increase  the  amount  of  gas  by  the 
CO  2  which  is  set  free  from  the  former.  Magnesia  usta  has  also  the 
advantage  of  forming  a  chlorid  which  has  a  mild  aperient  effect. 
According  to  Jaworski's  experiments,  the  continued  use  of  large 
quantities  of  Carlsbad  salt  and  the  thermal  waters  of  Carlsbad 
reduce  the  secretion  of  the  acids  of  the  stomach ;  this  might  ex- 
plain the  beneficial  influence  of  a  protracted  stay  at  Carlsbad  (see  p. 
323).  In  our  country  we  are  assured  that  the  Bedford  and  the 
Saratoga  Carlsbad  mineral  waters  have  an  equally  beneficial  effect. 
If  the  pains  in  the  region  of  the  stomach  continue  in  spite  of  the 
remedies  discussed  thus  far,  narcotics  are  prescribed,  especially 
extract  of  belladonna  (0.03  gm.  daily),  and  atropin  sulph  (0.0005  ^o 
0.00 1  or  y-^Q-  of  a  gr.),  given  with  advantage,  together  with  magnesia 
usta  or  ammonio-magnesium  phosphate — substances  which  not 
only  have  the  effect  of  reducing  pain,  but  also  inhibit  the  secretion 
of  the    glands;    codein   phosphate    (0.03    gr.   /:(  to   ^  daily,  is  a 


726  NEUROSES    OF    SECRETION. 

reliable  drug  for  this  purpose).  Cocain  muriate  is  not  suitable  on 
account  of  the  fact  that  its  effect  passes  away  rapidly,  but  bromid 
of  sodium  and  bromid  of  ammonium  (2.5  to  4.0  in  twenty-four 
hours),  when  taken  for  some  time,  often  do  good  service.  Stron- 
tium bromid  is  even  better  tolerated  than  the  sodium  or  ammonium 
salt. 

On  the  other  hand,  the  use  of  morphin  muriate  is  to  be  as  limited 
as  possible.  According  to  Hitzig  and  Alt,  morphin  muriate  is,  to  a 
great  extent,  excreted  in  the  gastric  juice  and  also  with  the  saliva, 
and  therefore  reaches  the  stomach  again  after  absorption.  Small 
quantities  of  morphin,  however,  excite  the  nerves  more  than  they 
calm  them. 

If  the  patients  complain  of  severe  pains  even  on  an  empty 
stomach  (without  being  able  to  prove  supersecretion  or  hyperes- 
thesia), then  lavage  of  the  stomach,  irrigation  of  the  mucous  mem- 
brane, and  internal  douches,  which  were  first  recommended  by 
Malbranc,  will  give  more  permanent  relief.  (See  pp.  286  and  287, 
Lavage  and  Douching.) 

With  very  stubborn  cramp-like  pains  in  the  region  of  the  pylorus 
(pylorospasm)  there  is  nothing  to  be  done  but  to  remove  the 
strongly  acid  contents  of  the  stomach  with  the  tube  and  to  wash 
out  the  stomach,  first  with  lukewarm  water,  then  with  bicarbonate 
of  sodium,  and  to  leave  a  small  part  of  the  latter  in  the  organ. 

The  electrical  treatment  has  been  used  successfully  by  Einhorn 
for  this  purpose,  and  he  especially  favors  the  internal  galvanization 
of  the  stomach.  Since  the  anode  has  a  calming  effect  upon  the 
irritated  nerves  (Heidenhan),  it  is  perhaps  best  to  introduce  the 
anode  with  the  intragastric  electrode  into  the  stomach  filled  with 
moderate  quantities  of  lukewarm  water,  and  to  apply  the  cathode 
to  the  sternum,  epigastrium,  or  spine. 

Constipation  is  to  be  fought  with  rhubarb  preparations  (pulv.  rad. 
rhei,  40.0;  natr.  sulph.,  20.0), 'Carlsbad  Sprudel  salts,  by  injections, 
massage  of  the  intestines,  and  glycerin  suppositories.  Since  super- 
acidity  is  frequently  a  neurosis,  we  must,  in  general,  influence  the 
nervous  system  favorably  by  a  sojourn  in  the  country,  in  the 
mountains,  at  the  seashore,  by  cold  rubbings,  gymnastics,  and 
abstention  from  severe  mental  labor.  A  treatment  recommended 
by  Biedert  and  Langermann  {loc.  cit.)  has  been  found  quite  service- 
able by  the  author.  The  stomach  is  first  washed  out  by  a  solu- 
tion   of  sodium  bicarbonate.     When  the  water  returns  clean  we 


PERIODIC    ATYPICAL    FLOW    OF    GASTRIC    JUICE.  727 

pour  in  a  one  per  cent,  suspension  of  magnesia  usta ;  when  this 
has  run  out  it  is  followed  by  a  one-half  per  cent,  solution  of  tannin. 
In  the  place  of  the  latter,  particularly  when  it  is  not  well  tolerated, 
we  often  use  a  suspension  of  bismuth  subnitrate;  when  the  pains 
are  severe,  the  author  prefers  the  latter  together  with  bismuth  sub- 
gallate. 

PERIODIC  ATYPICAL  FLOW  OF  GASTRIC  JUICE,  Gastroxynsis 

{Rossbach),  Gastroxie  {Lepine),  Gastrosuccorrhea  Periodica 

{^ReicJunatiti). 

Gastroxynsis,  or  periodic  flow  of  gastric  juice,  is  an  atypical 
secretion  of  the  peptic  glands,  atypical  because  it  does  not  occur 
after  a  normal  digestive  stimulation,  but  rather  when  the  stomach 
is  empty.  The  attacks  are  associated  with  intense  gastric  distress, 
severe  spasmodic  pain,  and  vomiting  of  considerable  quantities 
of  very  acid  gastric  juice.  This  peculiar  neurosis  is  found  only 
among  the  educated  classes,  and  particularly  among  those  indi- 
viduals who  are  subjected  to  unremitting  mental  exertion.  In 
exceptional  cases  persons  belonging  to  the  laboring  classes  are 
attacked  by  it.  The  malady  occurs  in  attacks  which  last  from  one 
to  three  days,  returning  in  some  instances  every  week,  and  in 
others  at  intervals  of  months.  The  attacks  are  more  frequent  when 
the  mental  exertion  is  severest,  and  become  rare  as  soon  as 
pauses  of  mental  rest  intervene.  During  vacation  of  these  brain- 
workers,  or  sojourn  at  the  seashore  or  in  the  mountains,  the  attacks 
disappear  entirely,  to  return  again  when  the  sufferer  applies  him- 
self to  his  profession.  The  pains  which  are  most  probably  caused 
by  irritation  of  the  mucosa,  by  the  intensely  acid  secretion, 
are  generally  preceded  by  nausea,  eructation,  and  pyrosis.  Eventually 
the  emesis  of  large  quantities  of  acid  liquids  supervenes,  and,  as  a 
rule,  terminates  the  attack.  The  sufferers  generally  recuperate 
quickly.  Jiirgensen  and  Ewald  have  reported  cases  of  typical 
migraine,  that  were  also  associated  with  superacidity.  Rossbach 
{Deiitsch.  Archil'  f.  klin.  Med.,  Bd.  xxxv,  1885)  and  Rosenthal 
{loc.  cit.)  have  suggested  hypotheses  attempting  to  explain  the 
pathogenesis  of  periodic  flow  of  gastric  juice;  their  theories  are 
not  supported  by  experimental  evidence,  and  have  not  at  all  cleared 
up  the  subject. 

Etiology. — Among  the  incidental  causes,  we  meet  with  exces- 
sive and  exhausting  mental  exertion,  intense  emotional  excitement. 


■J2?>  NEUROSES    OF   SECRETION. 

anger,  nicotin  poisoning,  and  occasionally  dietetic  errors.  The 
so-called  periodic  flow  of  gastric  juice,  as  first  described  by  Reich- 
mann  [Berlin  klin.  Wochenschr.,  1882,  Nr.  40),  and  the  gastroxynsis 
of  Rossbach,  are,  in  our  opinion,  simply  phases  of  the  same  neurosis, 
not  different  diseases. 

Symptomatology. — The  attacks  occur  very  acutely,  more  fre- 
quently on  an  empt\"  stomach,  and  with  a  feeling  of  pressure  in 
the  head  increasing  to  intense  headache,  pain  in  and  over  the  eyes, 
distress,  pressure,  and  fullness  in  the  stomach,  increasing  to  gas- 
tralgia.  Eructation,  pj-rosis,  and  nausea  usher  in  abundant  v^omit- 
ing  of  highly  acid  mucous  masses,  the  acidit}^  of  which  is  equal  to 
0.2  to  0.5  per  cent,  of  HCl.  Repeated  vomiting  will  bring  up  mucus 
and  bile.  When  the  vomit  occurs  while  the  stomach  still  contains 
ingesta,  this  will  show  the  same  chemical  reactions  as  are  found 
in  hyperacidit^^  The  drinking  of  water  relieves  the  gastric  distress 
by  diluting  the  acid,  but  generally  increases  the  vomiting.  In  our 
experience  the  attacks  occur,  as  a  rule,  in  the  middle  of  the  night, 
or  in  the  early  hours  of  the  morning.  The  patient  has  a  ver}^  pale 
appearance  and  the  extremities  are  frequently  cold.  A  few  hours 
after  the  first  vomiting  of  gastric  juice  the  attack  may  be  repeated, 
and  again  an  equally  large  quantity  of  gastric  secretion  contain- 
ing no  food  particles  whatever  may  be  vomited  up.  Occasionally 
the  gastric  pains  are  the  only  symptom,  and  headache  follows  later 
on  ;  in  fact,  the  symptoms  might  be  differentiated  into  gastric  and 
cerebral  symptoms — at  times  the  former  prevail,  and  at  others  the 
latter.  The  very  acid  masses  in  the  stomach  very  likely  cause  a 
reflex  spasmodic  pylorospasm.  Eructation,  insufficiency  of  the 
cardia,  and  pneumatosis  are  frequent  accompaniments.  Periodic 
atj^pical  flow  of  gastric  juice  may  be  an  independent  neurosis  of 
secretion,  or  reflexly  caused  by  diseases  of  the  central  nervous 
system.  The  gastric  crises  occurring  in  tabes  have  been  classed 
with  periodic  secretion  by  some  authors,  but  according  to  von 
Noorden  (Charite  Annalen,  1890),  Bouveret  [loc.  cit.,  p.  680),  and 
Boas  {Deutsch.  ined.  Wochenschr.,  1889,  Nr.  42)  the  liquids  vom- 
ited in  gastric  crises  are  not  always  acid,  and  frequently  may  be 
found  alkaline.  They  are  not  associated  with  the  very  severe  phe- 
nomena of  highly-increased  acidit}'  of  gastric  juice;  namely,  the 
strong  pyrosis,  and  the  feeling  of  a  corrosive  substance  in  the 
stomach.  Bouveret  has  expressed  his  doubt  concerning  the  exist- 
ence of  a  central  form  of  periodic  gastrosuccorrhea. 


CLINICAL  HISTORY  OF  ATYPICAL  FLOW  OF  GASTRIC  JUICE.        729 

Diagnosis. — Gastroxynsis  may  be  confounded  with  the  migraine 
associated  with  gastric  symptoms,  with  intermittent  forms  of  severe 
hyperchylia,  and  with  the  gastric  crises.  The  diagnosis  can  be 
made  by  chemical  analysis  of  the  vomited  matter.  The  attacks 
usually  occur  in  the  midst  of  good  health,  and  the  severe  thirst, 
loss  of  appetite,  cephalalgia,  and  great  prostration  are  characteristic 
symptoms.  Rossbach  found  an  acidity  of  four  per  thousand  (HCl) 
in  one  of  his  cases,  and  Boas  found  that  there  was  a  hyperacidity 
even  in  the  intervals  between  the  attacks,  and  that  the  amount  of 
gastric  juice  during  the  attacks  was  not  much  increased  as  com- 
pared to  that  found  in  the  intervals. 

Example  I. — Miss  M.  G.,  age  twenty-four,  of  neuropathic  extrac- 
tion, has  frequently  had  attacks  of  vomiting  and  gastric  pain  during 
childhood.  For  about  six  years  she  has  suffered  with  intense 
pyrosis,  which  was  relieved  by  bicarbonate  of  sodium  tablets. 
Sometimes  the  heartburn  ceased  after  the  ingestion  of  food.  She  is 
a  music  teacher,  and  frequently  spends  eight  to  ten  hours  a  day 
teaching  pupils  and  giving  singing  lessons.  The  appetite  is  at 
all  times  very  good,  bowels  slightly  constipated.  The  acidity  after 
our  double  test-meal  taken  in  the  interval  between  the  attacks  is 
equal  to  0.3  per  cent.  HCl.  About  once  a  week  she  has  distress- 
ing attacks  of  gastralgia,  associated  with  severe  headache  and 
vomiting  of  very  acid  liquid  masses.  The  attacks  occur  generally 
between  two  and  three  o'clock  in  the  morning,  when  she  has  spent 
a  day  at  hard  work  teaching  pupils.  The  patient  awakes  suddenly 
with  a  feeling  extending  from  her  stomach  to  her  throat,  which  is 
described  as  a  twisting  of  the  gullet.  Severe  cephalalgia,  giddiness, 
nausea,  and  vomiting  follow.  Sometimes  she  does  not  vomit,  but  the 
attack  is  passed  off  by  rapidly  drinking  a  half-pint  of  water  with  a 
teaspoonful  of  bicarbonate  of  soda.  Physical  examination,  entirely 
negative.  Urine,  the  indican  is  increased.  Uric  acid,  ratio  high.  No 
splashing  sound  in  the  stomach  prior  to  ingestion  of  food  or  drink. 
Acidity  of  filtrate  of  vomited  matter,  which  apparently  was  free  from 
bile,  was  equal  to  2.8  per  thousand  (HCl),  or  0.28  per  cent.  The 
fact  that  the  acidity  was  less  during  the  attack  than  during  the  in- 
tervals, suggested  that  the  HCl  had  been  neutralized  through  bile, 
duodenal  secretions,  or  saliva,  but  the  careful  examination  for  these 
constituents  was  negative.  During  a  summer  vacation  in  which 
the  patient  undertook  a  trip  to  Europe,  she  vomited  daily  from  sea- 
sickness, but  in  three  months,  while  she  was  in   Germany,  she  did 


730  NEUROSES    OF    SECRETION. 

not  have  one  attack.  On  returning,  the  acidity,  after  a  similar  test- 
meal  as  before  stated,  was  equal  to  1.5  per  thousand  (HCl).  Gen- 
eral  condition  much  improved. 

Example  II. — This  case  is  that  of  a  colleague,  a  friend  of  the 
author,  who  has  described  his  case  with  great  accuracy  on  repeated 
occasions.  The  attacks  usually  occur  at  night,  associated  with 
headache  and  gastric  distress,  and  culminate  in  the  vomiting  of 
large  masses  of  highly  acid  material.  The  doctor  is  an  indefatiga- 
ble brain-worker,  allows  himself  very  little,  if  any,  recreation,  and 
rarely  leaves  the  house.  His  general  nutrition  is  good,  and  he 
has  found  that  his  attacks  are  rapidly  relieved  by  the  taking  of 
ordinary  cane  sugar  (Ewald). 

Periodical  vomiting,  when  associated  with  hyperacidity,  must  be 
carefully  distinguished  from  gastroxynsis. 

Treatment. — This  includes,  in  the  first  place,  the  avoidance  of 
stimulants  and  narcotics;  alcohol  and  tobacco,  as  well  as  strong 
coffee.  It  is  most  essential  that  the  patients  should  avoid 
mental  overwork.  They  should,  in  fact,  refrain  from  brain-work 
altogether,  and  allow  themselves  three  to  four  months  a  year  to 
enjoy  recreation  in  the  mountains  or  at  the  seashore.  Physical 
exercise  should  be  indulged  in  moderately  but  systematically. 
The  bicycle  is  an  excellent  remedy  for  periodic  flow  of  gastric 
juice;  and  also  horse-back  riding,  swimming,  rowing,  fencing, 
gymnastic  exercises,  and  out-door  games.  During  the  attack 
itself,  the  effects  of  the  excess  of  acid  should  be  counterbalanced 
by  copious  drafts  of  suspensions  of  calcined  magnesia,  ammonio- 
magnesium  phosphate,  or  bicarbonate  of  sodium.  Where  the 
vomiting  has  occurred  at  short  intervals,  one  should  not  hesitate 
to  pass  the  stomach-tube,  wash  out  the  stomach  with  sodium  bi- 
carbonate, and  afterward  treat  the  mucosa  with  suspensions  of  bis- 
muth subgallate  (oij  to  Oj).  A  mustard  plaster  should  be  placed 
over  the  epigastrium.  If  this  can  not  be  conveniently  had,  a  hot- 
water  bag  will  act  similarly.  The  bromid  of  strontium  and  bromid 
of  ammonium,  in  doses  of  30  grs.  three  times  a  day,  have  an  un- 
deniable effect  upon  the  frequency  of  the  attacks.  The  diet  should 
be  carefully  adjusted  to  the  digestive  capacity  of  the  stomach.  We 
usually  recommend  Penzoldt's  diet  order,  which  is  given  among 
the  diet  lists.  In  the  intervals  between  the  attacks  the  patients 
should  undergo  treatment  as  outlined  for  hyperacidity. 


THE    MORNING    CONTENTS    OF    THE    FASTING    STOMACH.  73 1 


CHRONIC  CONTINUOUS  FLOW  OF  GASTRIC  JUICE  (Chronic 

Hyper-  or  Supersecketign  {Riegel),  Gastrosuccorrhea 

Chronica  [Reichmanji). 

We  have  our  doubts  whether  such  a  condition  of  permanent 
irritation  of  the  gastric  secretory  nerves  and  uninterrupted  secre- 
tion exists  as  a  primary  disorder.  Chronic  gastrosuccorrhea,  which 
Reichmann  claimed  to  have  observed  and  first  described  in  1882 
{Berlin,  klin.  Wochenschr.,  1882,  Nr.  40;  1884,  Nr.  48;  1887,  Nr. 
12)  as  a  disease  peculiar  to  itself,  is  stated  by  him  to  be  a  disorder 
characterized  by  the  chronic  uninterrupted  secretion  of  gastric  juice 
at  all  times,  even  where  there  is  no  food  in  the  stomach.  In  a  fasting 
condition  in  the  morning,  Reichmann  and  others  claim  that  gastric 
juice  could  be  drawn  from  the  stomach  in  these  cases.  As  we  have 
seen  in  the  description  of  the  organic  gastric  diseases,  particular!)-  in 
severe  reflex  neuroses,  in  dilatation,  and  gastric  ulcer,  continued  flow 
of  gastric  juice  is  a  frequent  symptom,  associating  itself  with  altera- 
tion and  loss  of  substance  in  the  mucosa.  Occurring  as  a  secondary 
affection,  it  may  still  be  able  to  effect  severe  damage  to  the  gas- 
tric walls.  The  diagnosis  of  this  hypothetical  disease  hinges  upon 
the  presence  of  gastric  juice  containing  HCl  and  ferments  in  the 
jejune  or  fasting  stomach.  This  question  has  been  very  carefull)- 
investigated  by  Schreiber  {DciitscJi.  Archiv  f.  klin.  Medizin,  Bd.  liii, 
S.  90).  He  found,  in  Konigsberg,  that  in  over  70  per  cent,  of  his 
patients  a  digestive  secretion  was  contained  in  the  fasting  stomach. 

We  have  very  carefully  investigated  this  subject  from  quite  a 
large  clinic  in  Baltimore,  and  can  confirm  the  results  of  Professor 
Schreiber.  Physiologically  speaking,  an  absolutely  clean  and 
empty  stomach  should,  in  the  morning,  contain  no  gastric  juice,  as 
the  glandular  apparatus  is  normally  in  a  resting  state,  but  practi- 
cally the  human  stomach  is  very  rarely,  or  perhaps  never,  in  this 
condition.  It  contains  at  all  times  epithelial  detritus,  dust,  bacteria, 
secretions  from  the  mouth,  larynx,  and  pharynx,  particularly 
saliva,  which  at  different  intervals  are  swallowed  consciously  or 
unconsciously.  Now  these  albuminous,  mucous  masses,  which  are 
generally  weakly  alkaline,  and  which  collect  particularly  during  the 
night,  incite  the  specific  gastric  glands  to  secrete  their  physiologi- 
cal product  just  as  any  other  weakly  albuminous  food  would  do. 
This  is  a  kind  of  pseudo  or  frustrate  digestion,  because,  so  far  as 
nutrition  is  concerned,  this  slow  digestion  going  on  constantly  is  of 


732  NEUROSES    OF    SECRETION. 

no  value.  (See  pp.  138,  139,  and  140.)  In  dilatation  this  slight 
pseudo  digestion,  which  is  present  perhaps  at  all  times,  is  aug- 
mented and  multiplied  by  the  permanent  presence  of  actual  food 
masses.  The  frustrate  digestion  becomes  a  real  one.  In  all  dilata- 
tions with  retention  of  food  we  have  a  permanent,  real  digestion 
and  an  augmented  permanent  secretion  corresponding  to  it. 

This  so-called  continued  hypersecretion  leads  to  the  digestion 
and  assimilation  of  proteids  and  albuminous  bodies  of  the  food, 
while  the  normal  digestion  of  carbohydrates  is  impeded.  The 
phenomena  that  are  claimed  to  be  typical  of  chronic  continued 
hypersecretion  are  unavoidable  consequences  of  dilatation.  The 
cardinal  point  of  distinction, — namely,  that  digestive  secretions  are 
contained  in  the  stomach  on  the  morning  following  a  very  effective 
washing  out  executed  the  evening  before,  is  certainly  not  pecu- 
liar to  chronic  hypersecretion,  but  occurs  also  with  dilatation. 
Schreiber  has  called  attention  to  the  fact  that  it  is  exceedingly  diffi- 
cult— even  impossible — to  completely  evacuate  and  clean  out  a  di- 
lated stomach.  During  gastrotomies  food  substances  have  been 
found  in  the  stomach,  notwithstanding  very  energetic  efforts  to  free 
it  of  all  remnants  beforehand.  When  a  patient  with  a  dilated 
stomach  is  to  be  tested  for  the  gastric  contents  prior  to  taking  food 
in  the  morning,  it  is  expedient  not  to  be  satisfied  with  the  simple 
expression  method  of  Ewald  where  this  is  negative,  but  to  place 
the  patient  in  a  horizontal  position,  and,  while  he  makes  efforts  at 
straining  as  if  he  were  bearing  down  for  stool,  the  operator  must 
compress  the  stomach  near  the  fundus,  which,  in  these  cases,  is 
sometimes  found  below  the  umbilicus. 

In  the  reports  of  a  number  of  advocates  of  chronic  hypersecre- 
tion as  a  primary  disease  per  se,  one  frequently  finds  that  the 
authors  state  that  small  quantities  of  food  remnants  were  found  in 
the  fasting  stomach.  The  argument  generally  follows  that  such 
small  quantities  of  food  could  not  be  the  cause  of  the  large 
quantity  of  gastric  juice  secreted,  contending  that  the  latter  must 
have  been  secreted  spontaneously.  At  the  same  time,  the  illogical 
position  of  these  writers  is  demonstrated  by  their  assertion  that 
the  momentary  contact  of  a  soft  stomach-tube  with  the  mucosa  is 
the  cause  of  the  secretion  of  80  to  100  c.c.  of  gastric  juice.  This 
assertion,  it  should  not  be  forgotten,  is  made  by  a  .  mber  of  those 
who  have  found  food  remnants  in  the  stomachs  01  '""ese  cases. 
That    is  to    say,  the   effort   is   made   to   ignore  the   ph_)    "ological 


SMALL   AMOUNTS    OF    HYDROCHLORIC    ACID    PRESENT.  733 

stimulus  of  food,  which  is  contained  in  the  stomach  for  hours,  and 
emphasize  the  rather  insignificant  momentary  stimulation  caused 
by  the  introduction  of  a  tube.  As  Schreiber  correctly  points  out, 
the  freedom  of  the  stomach  contents  from  food  particles  is  very 
often  only  an  apparent,  not  a  real,  one.  It  is  caused  by  imper- 
fections in  our  methods  of  investigation,  and  when  one  closely 
considers  the  facts  of  chronic  hypersecretion,  as  they  are  de- 
scribed by  the  adherents  of  Reichmann,  they  seem  to  be  identi- 
cal with  those  of  dilatation.  We  have  been  able  to  exclude  the 
hypothetical  factor  of  the  stomach-tube  in  causing  a  secretion  of 
gastric  juice  in  a  normal  fasting  stomach.  In  a  number  of  our  stu- 
dents to  whom  we  administered  a  hypodermic  injection  of  apo- 
morphin  before  they  had  eaten  anything  in  the  morning,  we 
demonstrated  the  presence  of  HCl  in  the  vomited  matter.  There 
is,  therefore,  to  some  degree  a  physiological  normal  continued 
secretion  of  gastric  juice,  as  Schreiber  correctly  asserts  {Detitsch. 
viedizin.  Wochenschr.,  1894,  Nr.  18-21),  the  stomach  secretes 
gastric  juice  normally  and  independently  of  the  ingestion  of  food. 
Ewald  and  Boas  cite  a  case  which  has  been  quoted  by  Riegel 
{Deutsdi.  ined.  Woclienschr.,  1893,  Nr.  31,  32)  in  opposition  to 
the  views  of  Schreiber.  This  female  patient  had  a  peculiar  gastric 
neurosis  founded  on  a  hysterical  basis.  For  six  years  the  patient 
vomited  everything  that  was  ingested  ;  fluids  were  vomited  imme- 
diately and  solid  food  after  two  to  four  hours.  When  she  had 
taken  lOO  c.c.  of  water  on  an  empty  stomach  in  the  morning,  she 
vomited  it  very  soon  thereafter,  and  Ewald  and  Boas  could  not  find 
free  HCl  in  it,  and  therefore  concluded  that  the  fasting  stomach 
secretes  no  gastric  juice  under  normal  conditions.  Aside  from  the 
fact  that  this  woman  may  have  had  a  spasm  of  the  esophagus 
or  cardia  preventing  the  small  amount  of  water  from  ever  reach- 
ing the  stomach,  it  is  not  fair  to  decide  a  physiological  question 
from  results  obtained  from  a  chronic  neurotic  patient ;  for,  as  we 
know,  in  this  class  of  individuals  the  greatest  variation  in  the 
state  of  the  gastric  secretion  exists.  The  results  obtained  on 
human  beings  with  gastric  fistula  (see  W.  Beaumont  on  his 
Canadian  hunter,  Alexis  St.  Martin-Kretschy-Richet)  are  inad- 
missible to  the  solution  of  this  physiological  question,  because  they 
are  made  on  individuals  under  pathological  conditions. 

The    existence    of  HCl  in  normal    stomachs    may    be    demon- 
strated by  giving  healthy  individuals  long  pieces  of  thin  thread, 
48 


734  NEUROSES    OF   SECRETION. 

which  with  some  practice  they  can  learn  to  swallow  on  an  empty 
stomach  ;  this  silk  or  thread  is  so  thin  that  it  does  not  irritate  the 
gastric  wall  to  any  degree,  at  least  not  so  much  as  a  stomach-tube ; 
the  thread  is  then  rapidly  withdrawn  and  pressed  between  pieces 
of  Congo  paper,  when  it  can  be  seen  that  the  Congo  paper  turns 
dark  blue.  We  have  also  introduced  the  thread  already  stained 
with  Congo  red,  and  obtained  the  blue  discoloration  from  fasting 
normal  stomachs.  Undoubtedly  there  are  great  individual  varia- 
tions in  the  genuine  as  well  as  in  the  frustrate  digestion,  caused  by 
the  secretive  power  of  the  glands  and  the  character  of  the  food. 
Morbid  conditions  influence  both  of  these  types  of  digestion, 
quantitatively  and  qualitatively.  Conditions  which  incite  the  glands 
will  increase  the  HCl,  and  conditions  which  weaken  the  mucosa, 
such  as  gastritis,  diminish  the  HCl  during  real  digestion  after 
meals,  as  well  as  during  the  frustrate  digestion  occurring  during 
the  night  and  on  a  fasting  stomach.  These  variations  are  also 
frequently  found  in  dilatation.  If  the  gastrectasia  occurred  on  the 
basis  of  an  ulcer,  the  true  secretion,  as  well  as  the  permanent  secre- 
tion of  a  frustrate  character,  will  be  increased,  and  reversely,  when 
carcinoma  or  chronic  gastritis  is  present  together  with  dilatation, 
both  kinds  of  secretion  will  be  diminished,  or  they  may  not  contain 
HCl  at  all.  In  diagnosing  a  dilated  stomach  it  is  important  to 
bear  in  mind  that  a  stomach  may  be  very  much  enlarged  and  still 
its  greater  curvature  may  not  have  descended  to  any  considerable 
extent.  Frequently  the  very  cause  which  has  brought  about  the  dila- 
tation,— for  instance,  perigastritis,  or  adhesions  about  the  stomach, — 
make  a  descent  of  the  greater  curvature  impossible,  simply  because 
it  can  not  descend,  being  bound  down  into  this  position  in  the  upper 
part  of  the  abdomen  by  inflammatory  adhesions.  Therefore  it  is 
possible  that  a  stomach  may  be  dilated  and  yet  give  no  splashing 
sound  about  the  neighborhood  of  the  umbilicus,  nor  need  it  be 
much  displaced  from  its  normal  position.  The  stomach  may,  in 
fact,  enlarge  in  an  upward  and  backward  or  lateral  direction  when 
its  descent  is  made  impossible  by  adhesions.  The  presence  or 
absence  of  food  particles  in  contents  drawn  from  the  fasting  stomach 
can  not  always  be  recognized  by  the  .  ked  eye.  What  looks  like 
a  turbid  liquid  free  from  ingesta  to  t.  naked  eye,  Avill  often 
show  undigested  rice,  bread,  and  other  Cc  johydrates  under  the 
microscope.  We  have  personally  seen  cases  which  according  to  the 
description  of  Reichmann  and  Riegel  would  have  to  be  classed  as 


GASTROSUCCORRHEA    CURED    BY    RECTAL    FEEDING.  735 

typical  chronic  hypersecretion,  in  which  the  stomach  Avas  appar- 
ently in  its  normal  place,  and  no  organic  gastric  disease  could  be 
determined  with  the  most  exact  methods  of  examination.  In  three 
of  these  cases  we  could  extract  from  100  to  150  c.c.  of  gastric 
juice  from  the  fasting  stomach,  apparently  containing  no  food  con- 
tents but  frequently  containing  traces  of  bile.  The  acidity  of  this 
secretion  when  filtered  was  equal  to  80°  HCl  by  decinormal  solu- 
tion of  sodium  hydroxid  and  either  Congo  or  dimethyl-amido- 
benzol. 

The  total  acidity  was  no  in  one  of  the  cases — that  of  a  young 
bank  clerk  twenty-four  years  of  age.  He  also  suffered  from  con- 
stipation, pyrosis,  increasing  to  pain,  and  vomiting  which  came  on 
very  soon  after  meals.  The  examination  of  the  contents  one  hour 
after  our  complex  test-meal  gave  the  following  results :  Total 
acidity,  108;  free  HCl,  84;  biuret  reaction,  positive ;  patellar  and 
pupillary  reflexes,  normal.  For  eight  consecuti\'e  days  free  HCl 
and  gastric  ferments  could  be  detected  in  the  contents  from  the 
fasting  stomach.  As  his  trouble  was  persistent  and  he  was  deter- 
mined to  get  well,  he  consented  to  a  course  of  exclusive  rectal 
feeding.  He  was  nourished  for  ten  days  by  the  rectum,  and  at  the 
same  time  his  stomach  was  washed  out  with  solutions  of  magnesia 
usta  every  day.  Under  these  conditions,  when  no  food  was  ingested 
per  OS,  the  gastrosuccorrhea  rapidly  diminished,  and  disappeared 
entirely  on  the  fourth  day,  so  that  not  even  the  swallowed  masses 
of  mucus  and  saliva  could  sufficiently  stimulate  the  mucosa  to  pro- 
duce a  secretion  of  HCl.  This  has  occurred  in  three  of  our  cases 
where  the  amounts  of  gastric  juice  found  on  an  empty  stomach 
exceeded  100  c.c.  Asecond  one  of  these  cases  was  that  of  a  young 
girl  with  chronic  flow  of  gastric  juice,  who  was  operated  on  upon 
our  suggestion  by  Dr.  R.  W.  Johnson  at  the  Maryland  General 
Hospital.  After  the  abdomen  was  opened  and  the  stomach 
incised,  no  anatomical  cause  for  the  persistent  vomiting  and  gas- 
tralgia  could  be  detected.  On  replacing  the  stomach,  however, 
and  inserting  the  finger  into  the  pylorus,  a  rather  sharp  bend  in 
the  duodenum  was  evident  to  the  author.  Undoubtedly  this  kink 
became  more  manifest  when  food  was  ingested,  the  stomach 
thereby  dragging  upon  this  acute  angle  in  the  duodenum.  It  was 
one  of  those  cases  of  motor  insufficiency  which  Broadbent  has 
described  {British  Medical  J ottr.,  vol.  11,  1893,  pp.  1 193  and  126S)  due 
to   kinking    of  the  duodenum  hx  an   abnormallv  short   duodeno- 


736  NEUROSES  OF  SECRETION. 

hepatic  ligament.  During  the  operation  the  pylorus  was  also 
enlarged  by  sewing  together  the  oblique  incision  which  had  been 
made  (it  is  true  only  for  explorative  reasons),  but  was  in  closing 
up  sutured  in  such  a  way  as  to  resemble  a  pyloroplastic  operation. 
The  patient  made  a  perfect  recovery,  and  there  was  no  more  gastro- 
succorrhea,  vomiting,  or  gastralgia. 

She  remained  in  the  hospital  for  two  months  after  the  operation, 
and  was  not  supplied  with  specially  prepared  diet,  but  lived  upon  the 
regular  hospital  fare  without  gastric  distress,  and  was  discharged  in 
good  condition.  Einhorn  (Joe.  cit.,  p.  313)  agrees  with  Reichmann 
as  to  the  existence  of  a  pathological  continuous  gastrosuccorrhea, 
although  he  restricts  this  name  to  cases  not  presenting  organic 
lesions  of  the  stomach.  Whenever  the  latter  exists  (lesions)  he 
looks  upon  the  accompanying  gastrosuccorrhea  as  a  consequence 
of  the  main  trouble,  but  not  as  a  cause  of  the  organic  lesion.  It  is 
the  exclusion  of  these  organic  troubles,  particularly  of  enlargements 
of  the  stomach  and  motor  insufificiency,  in  which  the  greater  curva- 
ture has  not  descended,  which  presents  so  much  difficulty.  In  all 
the  cases  of  chronic  continued  hypersecretion  that  we  have  ex- 
amined with  regard  to  this  question,  we  were  enabled  to  discover 
some  organic  lesion,  most  frequently  an  atony,  pyloric  stenosis,  or 
dilatation  from  some  cause.  After  a  careful  investigation  of  a  large 
clinical  material  we  can  not,  from  our  own  experience,  affirm  the 
existence  of  chronic  gastrosuccorrhea  as  an  idiopathic  neurosis 
sid  generis.  We  hold  that  chronic  hypersecretion  is  not  a  sponta- 
neous, idiopathic  neurosis,  but  a  secondary  symptomatic  phe- 
nomenon. We  base  our  conclusion  upon  the  following  facts:  (i) 
That  gastric  juice  is  contained  normally  in  the  fasting  stomach  ; 
the  secretion  of  the  peptic  glands  being  set  up  by  the  presence  of 
mucus,  saliva,  dust,  bacteria,  epithelial  detritus,  etc.  (2)  That 
apparently  clear  gastric  juice  obtained  from  a  fasting  stomach 
may  show  presence  of  food  particles  microscopically.  (3)  That 
it  is  not  possible  to  exclude  dilatation  nor  ulcer  in  all  of  these 
cases,  particularly  when  the  dilatation  is  not  marked  by  the  descent 
of  the  greater  curvature.  (4)  The  liquid  obtained  from  undoubted 
dilatations  of  the  stomach  may  contain  absolutely  no  food  particles, 
thus  simulating  the  condition  for  chronic  gastrosuccorrhea.  (5) 
Gastric  contents  obtained  from  dilatation  of  the  stomach  do  not 
always  show  the  presence  of  products  of  imperfect  starch  diges- 
tion   (erythrodextrin).      This    is    particularly    the    case    when    we 


SYMPTOMATOLOGY    AND    DIAGNOSIS.  737 

meet  with  dilatation  accompanied  by  hyperacidity,  but  with  a  fair 
motiHty  or  where  the  peristalsis  is  only  periodically  lost.  In  any 
case  of  hyperacidity  it  is  possible  that  the  products  of  starch  diges- 
tion may  be  absent  when  very  little  carbohydrate  food  has  been 
ingested.  This  may,  of  course,  also  happen  with  gastrosuccorrhea. 
(6)  In  cases  of  typical,  so-called  chronic,  continued  supersecretion, 
the  symptoms  cease  entirely  and  the  stomach  contains  no  gastric 
juice  in  the  morning  after  the  patient  has  been  fed  by  the  rectum 
for  four  to  eight  days.  (7)  Diseases  presenting  the  classical 
picture  of  Reichmann's  disease  have  been  known  to  disappear 
entirely  after  a  gastro-enterostomy  or  a  pyloroplastic  operation 
was  performed. 

Symptomatology. — This  is  essentially  the  same  as  in  motor 
insufficiency  with  hyperacidity.     (See  chapter   on   this  subject.) 

The  periodic  flow  of  gastric  juice,  which  we  have  already 
described  (p.  727),  is  either  a  functional  neurosis  or  a  reflex  affection 
(tabes  dorsalis),  or  connected  with  an  affection  of  the  sympathetic. 
It  is  identical  with  the  gastroxynsis  of  Rossbach.  Possibly,  also, 
the  periodic  vomiting  of  Leyden  belongs  to  this  group  of  neuroses. 
The  chronic  gastrosuccorrhea  is  a  symptom,  and  has  not  the  claim 
to  be  considered  a  morbid  entit}"  like  the  periodic  or  spasmodic 
gastrosuccorrhea.  Chronic  flow  of  gastric  juice  may  be  a  compli- 
cation of  ulcer  and  motor  insufficiency.  From  a  pathological 
standpoint,  it  is  well  established  that  gastritis  may  accompany 
ulcer  as  well  as  dilatation  (Rokitansky,  Lebert,  Orth,  Cruveilhier). 
The  gastritis  which  accompanies  these  diseases,  and  which  shows 
hyperacidity,  has  been  called  by  Korczynski  and  Jaworski 
{Deutsch.  Arcliiv  f.  klin.  Med.,  Bd.  xlvii,  p.  5 78)  "  catarrhus 
acidus,"  and  by  Hayem  {Gazette  Hebdom.,  1892,  Nos.  33  and  34) 
it  has  been  designated  as  "  gastrite  hj^perpeptique."  These  ex- 
pressions signify  the  same  complexity  of  S3miptoms  as  those  first 
described  by  Reichmann  under  the  name  of  "  gastrosuccorrhea." 
The  "  gastritis  acida"  of  Boas  is  quite  a  different  thing  (p.  434),  a 
characteristic  form  of  chronic  gastritis. 

Diagnosis. — As  Boas  says,  the  main  question  to  decide  is  not 
whether  we  are  dealing  with  chronic  gastrosuccorrhea,  which  is 
not  very  difficult  to  find  out,  but  to  determine  which  disease  it 
is  a  consequence  of  The  most  frequent  causes  are  ulcer  and 
mechanical  insufficiency.  For  a  fuller  explication  of  these  sub- 
jects   and    their  consequences,  we  must  refer  to  the  chapters  in 


738  NEUROSES    OF   SECRETION. 

which  they  are  considered.  It  is  much  to  be  regretted  that  a 
number  of  authors  still  insist  upon  the  identity  of  chronic  gas- 
trosuccorrhea,  and  regard  the  symptom  or  complication  in  the 
light  of  a  disease  sid  generis. 

Treatment. — If  ulcer  or  dilatation  can  be  demonstrated  to 
exist,  the  treatment  must  be  directed  to  these  fundamental  causes 
(see  treatment  of  ulcer  and  motor  insufficiency).  In  the  absence 
of  any  definite  etiological  factor,  the  treatment  is  that  described 
under  hyperchylia.  Under  all  conditions  massage  of  the  stomach 
and  intestines,  intragastric  application  of  the  galvanic  and  faradic 
currents,  and  washing  out  of  the  stomach  are  very  essential  adjuncts 
to  treatment.  Where  there  is  much  secretion  of  gastric  juice,  even 
on  an  empty  stomach,  the  use  of  a  stomach-tube  can  not  be  con- 
sistently neglected.  It  is  the  only  way  to  remove  the  excess  of  secre- 
tion directly ;  then,  again,  the  best  treatment  of  a  hyperchylia  is  that 
which  is  supplied  directly  to  the  mucosa  in  the  form  of  irrigations 
with  calcined  magnesia,  sodium  bicarbonate,  tannin  (^  per  cent, 
solution),  and  suspensions  of  bismuth  subnitrate.  The  methodical 
use  of  alkalies  affords  great  relief  to  the  pyrosis  and  eructation, 
and  facilitates  carbohydrate  digestion.  The  alkalies  which  we 
recommend  most  strongly  are  the  magnesia  usta  and  the  ammonio- 
phosphate  of  magnesium.  Einhorn  speaks  very  favorably  of  spray- 
ing the  stomach  with  a  solution  of  nitrate  of  silver,  i  :  looo. 
Reichmann  administers  the  nitrate  of  silver  in  solution  or  in  gelatin 
capsules. 

The  diet  will  vary  with  the  underlying  causative  disease.  It  will 
be  either  that  for  ulcer  or  dilatation,  or  that  for  hyperchylia.  Where 
the  stomach  is  extremely  sensitive,  the  diet  orders  of  Penzoldt 
may  be  safely  tried,  because  they  are  very  sparing  and  make  little 
demands  upon  the  capacity  of  the  stomach. 


LITERATURE  ON  CHRONIC  GASTROSUCCORRHEA. 

1.  Reichmann,  Berl.  klin.  Wochenschr.,  1892,  No.  40  ;  1884,  No.  48  ;  1887, 
No.  12  u.  f. 

2.  Riegel,  Zdtschr.  f.  klin.  Med.,  Bd.  xi  u.  xir  ;  Milnchn.  nied.  Wochen- 
schr.,  1884,  Nos.  45,  46;  Deictsche  med.  Wochenschr.,  1887,  No.  29  ;  1892,  No, 
21  ;  Volkmann  s  Samtnl.klin.  Vortr'dge,  1886,  289;  Deutsche  med.  Wochenschr., 
1893,  Nos.  30.31. 

3.  Jaworski,  Zeitschr.  f.  klin.  Med.,  Bd.  xi,  Heft.  2  u.  3  ;  Micnchn.  med. 
Wochetischr.,  1887,  No.  7  u.  8  ;  Wien.  med.  Presse,  1886,  No.  52  ;  IVien.  med. 
Wochenschr.,  1887,  No.  49  u.  f. 


SUBACIDITY — HYPOCHYLIA.  739 

4.  Sticker,  Milnchn.  med.  Wochenschr.,  1886,  Nos.  32,  33. 

5.  Johnson,  E.  Y..,  Milnchn.  med.  Wochenschr.,  1887,  No.  48.  u.  f. 

6.  Vente,  A.,  Inaug.-Diss.,  Giessen,  1890. 

7.  Bouveret  et  Devic,  "  La  Dyspepsie  par  Hypersecretion  Gastrique  (Mal- 
adie  de  Reichmann),"  Paris,  1892.  (Monograph.) 

8.  Boas,"  Specielle  Diagnostik  u.  Therapie  d.  Magenkrankheiten,"  2.  Aufl. 

9.  Schreiber,  Jul.,  "  Ueber  den  continuirlichen  Magensaftfluss  (Secretio 
hydrochlorica  con\xn.\ii)''  Deutsche  med.  Wochenschr.,  1893,  Nos.  29,  30;  ibid., 
"Ueber  continuirlichen  Magensaftfluss,"  Deutsche  7ned.  Wochenschr.,  1894, 
Nos.  18,  20,  21. 

10.  Schreiber,  Jul.,  "  Gastrektasie  u.  deren  Verhaltniss  z.  chronisch  Hyper- 
secretion," Archiv  f.  Verdauungskrankh.,  Bd.  II,  S.  423. 

11.  Debove  et  Remond,  "  Les  Maladies  de  TEstomac." 

12.  Johnson  und  Behm  {Zeitschr.f.  klin  Med.,  Bd.  XXII,  S.  478),  report  106 
cases  of  supersecretion,  including  all  cases  where  slight  amounts  of  gastric  juice 
were  found,  and  give  complete  literature. 

13.  Reichmann,  Berl.  klin.  Wochenschr.,  1887,  No.  14. 

14.  Wolff,  Zeitschr.  f.  klin.  Med.,  Bd.  xvi. 

15.  V.  Korczynski  und  Jaworski,  Deutsches  Archiv f.  klin.  Med.,  Bd.  xlvii, 

s.  578. 

16.  Hayem,  "  Resume  de  I'Anatomia  Pathologique  de  la  Gastrite  Chro- 
nique,"  Gaz.  Hebdofn.,  1892,  Nos.  33,  34,  and  "  Ueber  Gastritis  parenchyma- 
tosa,"  Allgem.  Wien.  med.  Zeitiing,  1894,  No.  2  ff. 

17.  Strubing,  Zeitschr.f.  klin.  Med.,  1885,  Bd.  ix,  S.  381. 

18.  Leyden,  Zeitschr.f.  klin.  Med.,  1882,  Bd.  vi,  S.  605, 

19.  Rossbach,  Deutsches  Arch.  f.  klin.  Med.,  1885,  Bd.  xxxv, 

20.  Rosin,  "Ueber  das  Secret  des  niichternen  Magens,"  Deutsche  med. 
Wochenschr.,  1888,  No.  47. 

21.  Schreiber,  "  Ueber  den  continuirlichen  Magensaftfluss,"  Deutsche  med. 
Wochenschr.,  1893,  No.  30. 

22.  Martius,  F.,  "  Ueber  den  Inhalt  des  gesunden,  niichternen  Magens  und 
den  continuirlichen  Magensaftfluss,"  Deutsche  med.  Wochenschr.,  1894,  No.  32. 

23.  Lyon,  G.,  "  L' Analyse  du  sue  Gastrique,"  Paris,  1890. 

24.  Text-books  of  Leube,  Riegel,  Boas,  Ewald,  Debove  et  Remond, 
Bouveret,  Penzoldt,  Fleiner,  S.  Martin,  A.  Pick,  Mathieu,  Einhorn. 


SUBACIDITY  (Hypochlorhydria  or  Hypochylia), 
Subacidity,  as  a  neurosis,  is  a  disease  in  which,  even  during  the 
height  of  digestion,  gastric  juice  is  secreted  in  which  the  HCl,  and 
with  it  the  pepsin  and  rennin,  are  present  in  smaller  amounts  than 
normal.  We  will  not  consider  under  this  head  those  secretory 
anomalies  in  which  the  secretion  of  gastric  juice  is  absent  entirely. 
These  states  will  be  considered  under  Achylia  Gastrica  or  In- 
acidity.  In  subacidity  HCl  is  still  secreted,  but  in  such  small 
amounts   that   it   enters   into  combination  with  albuminous  foods 


740  NEUROSES    OF    SECRETION. 

entirely,  and  we  can  detect  it  only  as  combined  HCl.  Cases  in 
which  free  HCl  can  be  detected  by  Congo  paper  after  our  double 
test-meal  do  not  logically  belong  in  this  class  of  subacidity,  because 
the  presence  of  free  HCl  means  that  more  HCl  is  present  than  can 
enter  into  combination  with  the  food ;  there  is  an  excess  of  acid 
beyond  that  required  for  digestion.  Technically,  we  may,  therefore, 
define  hypochylia  as  a  secretory  neurosis  in  which  free  HCl  is 
absent  at  the  test-meal,  but  combined  HCl  and  the  ferments  are 
still  present.  Nervous  hypochylia  is  in  reality  but  a  phase  of 
nervous  dyspepsia  (or  neurasthenia  gastrica).  But,  as  it  is  desir- 
able to  represent  all  secretory  neuroses  seriatim,  we  have  here 
abstracted  the  symptoms  of  nervous  depression  of  gastric  secre- 
tion. It  was  formerly  believed  that  subacidity  was  always  con- 
nected with  some  organic  gastric  disease  (carcinoma,  gastritis),  or 
occurred  in  the  train  of  infectious  diseases,  or,  as  a  result,  with 
anemia  and  leukemia.  Subacidity,  however,  may  exist  on  a  purely 
nervous  substratum,  in  hysteria  and  neurasthenia  and  in  psychoses. 
It  then  occurs,  independently  of  anatomical  changes  in  the  stomach, 
as  a  functional  disturbance  of  the  secretory  nerves,  the  irritability 
of  which  has  been  reduced.  Functional  disturbances  of  this  char- 
acter may  be  limited  to  the  secretory  nerves  and  not  involve  the 
remaining  nervous  apparatus  of  the  stomach.  The  amount  of  HCl 
secreted  is  not  sufficient  to  saturate  the  albumin  present  in  the 
proteid  food;  in  other  words,  an  HCl  deficit  exists.  It  is  probable 
that  the  secretory  nerves  become  exhausted  sooner  than  the  motor 
nerves,  and  that,  therefore,  subacidity  may  be  an  expression  of  ex- 
haustion or  weakness  in  the  secretory  apparatus.  In  this  way  we 
have  repeatedly  observed  prolonged  subacidity  followed  by  pro- 
nounced hyperacidity. 

Etiology. — Nervous  subacidity  or  hypochylia  is  a  secondary 
phenomenon  occurring  with  neurasthenia,  hysteria,  tabes,  and  the 
psychoses. 

Symptomatology. — When  the  motor  function  of  the  stomach  is 
good,  symptoms  may  be  absent  entirely,  but  the  slightest  insuffi- 
ciency of  the  motor  power  is  rapidly  followed  by  decomposition  in 
the  gastric  contents,  caused  by  bacteria,  for  the  amount  of  HCl 
secreted  is  not  sufficient  to  inhibit  or  prevent  the  action  of  micro- 
organisms. As  a  consequence  of  this,  organic  acids  are  formed, 
and  gaseous  formations  create  gastric  discomfort,  and,  at  times, 
intestinal  distention.     There  is  nothing  characteristic  in  the  symp- 


DIAGNOSIS    AND    TREATMENT    OF    SUBACIDITY.  74 1 

tomatology  of  subacidity.  The  result  of  the  depressed  state  of 
the  secretion  and  the  general  symptomatology  are  the  same  as 
those  in  achylia  gastrica,  and  will  be  described  under  that  heading. 
It  is  natural  that  amylolysis  should  proceed  more  rapidly  in  the 
absence  of  free  HCl,  since  nothing  can  disturb  the  activity  of  the 
ptyalin  in  that  case.  On  the  other  hand,  the  digestion  of  meats, 
eggs,  etc.,  is  most  unsatisfactory.  As  HCl  is  one  of  the  principal 
normal  stimulants  to  peristalsis,  the  disease  is  frequently  accom- 
panied by  constipation,  which,  in  turn,  produces  increasing  putre- 
faction of  the  intestinal  contents,  which  is  more  pronounced  because 
the  disinfecting  action  of  the  HCl  is  missing. 

Differential  Diagnosis. — Carcinoma  and  chronic  gastritis  might 
be  confounded  in  the  incipient  stages  with  nervous  subacidity. 
(For  the  differential  diagnosis  from  carcinoma  and  gastritis,  we 
refer  to  the  chapters  on  these  diseases.)  But  when  the  enzymes, 
pepsin  and  rennin,  can  be  demonstrated  in  the  gastric  contents,  or 
even  if  only  the  proenzymes,  pepsinogen  and  rennin-zymogen  can 
be  demonstrated,  one  can  not,  as  a  rule,  exclude  chronic  gastritis 
and  carcinoma.  A  patient  and  prolonged  study  of  nervous  sub- 
acidity will  not  fail  to  demonstrate  that  great  variations  exist  in  the 
amount  of  hydrochloric  acid  that  is  secreted.  Occasionally  it  may 
be  found  that  a  transition  to  a  normal  acidity,  or  even  to  hyper- 
chylia,  has  taken  place.  Lactic  acid  is  a  very  rare  occurrence  in 
nervous  subacidity;  its  presence  and  the  Oppler-Boas  bacillus 
would  speak  for  carcinoma. 

Treatment. — In  most  cases  it  will  be  sufficient  to  supply  an 
amount  of  dilute  HCl  which  is  commensurate  with  the  deficit.  In 
rare  instances  it  will  be  impossible  to  administer  sufficient  HCl  to 
give  the  reaction  for  free  HCl,  because  it  is  not  well  tolerated  in 
this  quantity.  In  that  case  we  advise  adding  the  HCl  to  beef 
juice,  either  Wyeth's,  Valentine's,  or  the  Mosquera  beef  jelly. 
This  makes  a  sauce  which  can  be  poured  over  the  finely-divided 
meat  foods  that  are  to  be  eaten.  The  meat-dissolving  power  of 
the  acid  is  not  destroyed  by  this  method  of  preparing  it,  although 
the  acid  is  mostly  in  a  combined  state.  Abnormal  fermentations 
and  decompositions  are  rare,  and  therefore  the  stomach-tube  can, 
as  a  rule,  be  dispensed  with.  The  bitter  tonics — quassia,  cinchona, 
calumbo,  gentian — and  the  basic  orexin  (in  five-grain  doses  three 
times  a  day)  very  often  increase  the  appetite  and  favor  a  secretion 
of  HCl.     Strychnin  and  the  intragastric  use  of  the  faradic  current 


742  NEUROSES    OF    SECRETION, 

we  warmly  recommend  for  this  purpose.  When  the  motility  is 
good,  those  mineral  waters  which  are  rich  in  sodium  chlorid  are 
worth  a  trial.     (See  section  on  Mineral  Waters.) 

The  Diet. — It  is  an  interesting  fact  that  patients  with  sub- 
acidity  instinctively  avoid  a  meat  diet,  and  are  large  carbohydrate 
eaters.  It  is  well,  however,  not  to  let  them  persist  in  the  exclusive 
use  of  carbohydrates,  but  to  train  up  the  digestive  capacity  of  the 
stomach  to  a  more  abundant  digestion  of  proteids.  All  meats 
should  be  given  in  a  finely-divided  state;  before  the  meal,  it  is  well 
to  stimulate  the  appetite  and  secretion  by  giving  a  few  sardelles  or 
the  roe  of  potted  herring,  or,  what  is  more  palatable  and  easier  to 
procure  a  sandwich  spread  with  Russian  caviar.  Surf  baths,  cold 
sponge  baths  at  home,  proper  movements  of  the  bowels,  and  at 
least  eight  to  nine  hours  of  sleep,  are  indispensable  agents  in  the 
management  of  this  secretory  defect. 


CHAPTER  XII. 

ACHYLIA  GASTRICA. 

Synonyms. — Absence  of  the  Secretion  of  Gastric  Juice,  Nervous  Inacidity, 
Atrophy  of  the  Stomach,  Anadenia  Ventriculi,  Phthisis  Ventriculi,  Achlor- 
hydria. 

Nature  and  Concept. — The  term  achylia  gastrica  means,  liter- 
ally, without  gastric  chyle,  and  was  first  proposed  by  Einhorn 
{New  York  Medical  Record,  June  ii,  1892)  to  designate  a  class  of 
diseases  in  which  no  gastric  juice  is  secreted. 

The  affection  is  found  to  exist  in  two  varieties :  First,  the 
primary,  idiopathic,  possibly  inherited,  achylia  ;  secondly,  the  ac- 
quired or  secondary  achylia.  The  primary  idiopathic  or  sympto- 
matic achylia  is  characterized  by  the  fact  that  absence  of  secretion 
is  evident  before  any  marked  anatomical  changes  have  occurred  in 
the  mucosa  which  could  explain  the  loss  of  function.  It  is,  there- 
fore, as  a  rule,  not  regarded  as  a  result  acquired  from  a  real 
disease,  but  as  an  individual  peculiarity,  possibly  an  inherited 
functional  debility.  There  are  undoubtedly  persons  in  whom 
gastric  secretion  may  be  absent  for  years,  or  permanently  wanting ; 
yet  who,  apparently,  may  enjoy  robust  health.  The  majority  of 
these  individuals,  however,  have  suffered  from  frequent  dyspeptic 
complaints,  which  are  partly  of  a  purely  nervous  character.  In 
these  cases  severe  anemic  and  cachectic  conditions  are  usually 
absent,  and  while  the  general  nutrition  may  occasionally  be  found 
disturbed,  it  is  easily  remedied  with  proper  dietetic  treatment. 

The  last-named  type  of  cases  demonstrates  that  the  function  of 
the  stomach  may  be  permanently  lost  so  far  as  its  digestive  power 
is  concerned,  yet  with  no  apparent  effects  upon  the  general  con- 
stitution. A  very  convincing  argument  for  the  compensatory 
digestive  power  of  the  intestine  !  Lubarsch  ("Achylia  Gastrica," 
etc.,  von  Martius  u.  Lubarsch,  1897,  p.  74)  raises  the  question 
whether  gastric  digestion  may  not  be  entirely  dispensed  with,  or 
whether  it  is  not  superfluous,  which  of  course  implies  that  the 
secretion  of  HCl  may  possibly  be  an  unnecessary  function.    There 

743 


744  ACHYLIA    GASTRICA. 

can  be  no  doubt,  however,  that  deficiency  of  gastric  secretion  is  a 
disease.  Individuals  affected  with  symptomatic  achylia  are  very 
much  more  sensitive  in  general,  and  more  susceptible  to  gastric  dis- 
eases, than  their  feliow-men  equipped  with  normal  stomachs.  The 
idea  that  gastric  digestion  is  superfluous  and  dispensable  impresses 
us  as  being  a  reactive  opinion  induced  by  the  other  extreme  view  for- 
merly held,  according  to  which  the  stomach  was  the  most  important 
of  all  digestive  organs.  Gastric  secretion  is  by  no  means  a  useless 
function.  Lubarsch  says :  "  Those  who  have  lost  it,  have  one 
weapon  less  in  the  struggle  for  existence,"  and  clinical  experience 
teaches  that  persons  who  have  no  secretion  of  gastric  juice  are 
much  more  liable  to  diseases  of  the  stomach.  When  such  are 
attacked  by  intestinal  diseases,  the  prognosis  actually  becomes 
serious. 

Achylia  may  exist  upon  a  nervous  basis,  it  may  be  congenital, 
or  acquired,  in  consequence  of  some  organic  gastric  disease. 

The  results  of  the  examination  of  the  gastric  contents,  in  simple, 
uncomplicated  achylia,  are  quite  characteristic  :  The  fasting  stom- 
ach, examined  in  the  morning  before  any  food  has  been  taken, 
is  empty.  We  have  never  been  able  to  obtain  more  than  20  to  30 
c.c.  of  neutral,  slightly  mucoid  liquid ;  remnants  of  ingesta  of  the 
previous  day  are  never  observed.  One  hour  after  the  Ewald  test- 
breakfast,  the  contents  of  the  stomach  have  the  same  appearance  as 
they  have  in  the  mouth  before  they  are  swallowed.  This  appear- 
ance is  claimed  by  Einhorn  and  others  to  be  quite  characteristic. 
Contents  drawn  in  this  manner  are  generally  slightly  acid.  Blue 
litmus  paper  is  very  slightly  reddened.  The  total  acidity  varied  in 
our  cases  from  two  to  eight.  This  degree  of  acidity  can  be  found 
in  the  test-meal  before  it  is  eaten.  Whenever  the  acidity  of  the 
drawn  stomach  contents  does  not  exceed  that  of  the  meal  before  it 
is  swallowed,  it  may  be  safely  assumed  that  free  and  combined 
HCl  are  absent ;  in  other  words,  no  HCl  has  been  secreted. 
Whenever  the  total  acidity  is  equal  to  four,  it  is  due  to  acid  that  has 
been  introduced  in  the  food  ;  with  a  total  acidity  no  higher  than 
four,  one  hour  after  a  test-breakfast,  it  is,  therefore,  unnecessary  to 
make  further  complicated  analyses  for  the  detection  of  HCl.  The 
gastric  contents,  when  filtered  and  mixed  with  HCl  sufificient  to 
produce  the  reaction  with  Congo  paper,  can  not  digest  discs  of  egg- 
albumen. 

Milk  taken  by  achylic  patients  can  be  drawn  out  twenty  to  thirty 


ON  THE  NATURE  AND  CONCEPT  OF  "  ACHYLIA."       745 

minutes  afterward  perfectly  unchanged,  or,  rather,  uncoagulated. 
The  secretion  of  pepsin  and  rennin  is,  therefore,  absent.  By 
proper  tests  it  can  also  be  found  that  pepsinogen  and  renninzy- 
mogen  are  also  wanting.  Lubarsch  and  Martius  assert  that  the 
isolated  loss  of  HCl,  without  loss  of  secretion  of  pepsin  and  ren- 
nin, does  not  exist;  and  for  these  cases  of  loss  of  gastric  secre- 
tion (not  the  HCl  simply,  but  all  the  constituents  of  gastric  juice), 
the  terms  anacidity,  inacidity,  and  achlorhydria  are  not  as  expres- 
sive and  logical  as  the  designation  "  achylia  gastrica."  In  the 
progressive  destruction  of  the  mucosa  accompanying  carcinoma 
and  gastritis  there  are  stages  in  which  HCl  is  totally  wanting,  and 
yet,  by  proper  methods,  secretion  of  ferments,  or  of  the  pro- 
enzymes, can  be  detected.  All  other  cases  of  loss  of  secretion  not 
due  to  carcinoma  or  atrophic  gastritis  may  logically  be  classed  as 
achylia.  A  further  pronounced  sign  of  achylia  is  the  abnormally 
small  quantity  of  gastric  contents  found  one  hour  after  the  test- 
breakfast.  Biedert  ("  Diatetik  u.  Kochbuch,"  etc.,  1895),  who  suffers 
from  this  affection  himself,  found  that  his  stomach  was  very  rapidly 
emptied,  so  that  he  had  to  draw  the  contents  within  forty-five 
minutes  if  he  wished  to  obtain  any  at  all. 

Julius  Miller  iloc.  cit.,  Archiv  f.  Verdainuigskrank.,  Bd.  i,  p.  233) 
found  that  strong  solutions  of  sodium  chlorid  are  very  much 
diluted  when  they  are  brought  into  the  human  stomach.  It  is  further 
known  that  strong  solutions  of  common  salt,  when  brought  into  the 
stomach,  arrest  HCl  secretion.  The  tendency  to  dilute  solutions 
that  are  put  into  the  stomach  is  so  persistent  that  it  continues  even 
after  the  concentration  of  these  solutions  has  inhibited  the  HCl. 
It  is  not  known  whether  this  dilution  of  the  stomach  contents  is 
caused  by  absorption  of  solid  substances  or  by  the  secretion  of 
water  into  the  stomach  itself.  In  achylia  gastrica,  however,  the 
stomach  differs  very  much  in  this  respect  from  the  normal  organ, 
since  it  has  then  lost  its  power  of  diluting  the  gastric  contents. 

The  fact  that  concentrated  solutions  of  sodium  chlorid  inhibit 
the  secretion  of  HCl  has  been  made  available  in  the  treatment  of 
hyperacidity.  From  these  facts  it  is  very  probable  that,  in 
achylia,  we  are  dealing  not  only  with  loss  of  the  characteristic 
secretion,  the  gastric  juice  with  its  HCl  and  ferments,  but  also  that 
there  seems  to  be  no  secretion  of  any  kind  issuing  from  the 
mucosa.  The  diluting  secretion  of  the  stomach  is,  under  normal 
conditions,  not    exclusively  made  up  of  the   normal  gastric   juice, 


746  ACHYLIA    GASTRICA. 

and  we  are  here  confronted  with  a  physiological  function  of  a  very 
complicated  character,  concerning  which  very  little  of  a  positive 
nature  is  known.  There  is  a  general  consensus  of  opinion,  which  we 
can  confirm  on  the  basis  of  large  clinical  material,  that,  in  achylia, 
there  is  an  exceptionally  great  vulnerability  of  the  mucosa.  It  is 
a  frequent  experience  with  achylic  patients  to  find  that  particles 
of  the  mucosa  showing  slight  hemorrhages  are  unintentionally 
scraped  or  torn  off  during  the  drawing  of  test-meals. 

Lubarsch  {loc.  cit),  Einhorn  {loc.  cit.),  Biedert  [loc.  cit.),  Cohnheim 
{Archiv  f.  Vtrdatnmgskrank.,  Bd.  i,  p.  274),  Jaworski  {Munch,  vied. 
Wochenschr.,  1887,  Nr.  7  und  8),  have  observed  this  phenomenon, 
and  the  first-mentioned  author  asserts  that  the  vulnerability  of  the 
mucosa  in  achylia  is  as  great  as  in  carcinoma.  We  have  devised 
a  stomach-tube  with  a  lower  extremity  of  somewhat  harder 
rubber  than  the  remainder  of  the  tube.  It  is  beveled  off  like  a 
chisel,  and  its  edge  is  rather  sharp.  By  means  of  this  tube  we 
effect  the  chiseling  off  of  small  portions  of  the  gastric  mucosa, 
which  are  afterward  washed  out  for  diagnostic  purposes.  In 
achylia  it  is  almost  impossible  to  avoid  the  scraping  ofif  of  portions 
of  the  superficial  mucous  membrane,  no  matter  what  shaped  tube  is 
used,  and  if  it  is  desired  to  avoid  scraping  the  mucosa  at  all  it  is 
safer  to  use  a  tube  which  is  entirely  closed  at  its  lower  end  and 
has  but  one  velvet  eye-opening  at  the  side  (Tiemann  &  Co.,  New 
York).  This  is  an  entirely  different  procedure  from  the  accidental 
sucking  off  of  rather  large  pieces  of  mucosa  by  the  stomach-tube. 
Scraping  off  of  minute  particles  is  a  harmless  procedure,  but  the 
tearing  of  larger  pieces  by  suction  may  be  followed  by  extensive 
hemorrhages. 

Total  loss  of  gastric  secretion,  even  when  a  consequence  of  a 
fully-developed  atrophy  of  the  mucosa  (anadenia),  can  not  cause 
anemia  or  cachexia  per  se.  Those  cases  in  which  anemia  has 
been  observed  in  connection  with  achylia  were  most  probably 
complicated  by  a  mechanical  insufificiency  of  the  stomach,  or  by 
other  diseases ;  thus,  in  some  cases,  syphilis  or  tuberculosis,  and 
extension  of  the  atrophic  process  to  the  mucosa  of  the  intestine, 
have  complicated  the  gastric  derangement. 

The  credit  of  having  first  pointed  out  the  association  of  gastric 
atrophy  with  anemia  is  usually  attributed  to  S.  Fenwick  (lecture 
on  "  Atrophy  of  the  Stomach,"  T/ic  Lancet,  July  7,  1877 ;  also  "  On 
Atrophy  of  the  Stomach  and  Certain  Nervous  Affections  of  the 


ANEMIA  AND  ATROPHY  OF  THE  GASTRIC  GLAND.        74/ 

Digestive  Organs,"  London.  1880,  J.  and  A.  Churchill).  Both  Ein- 
horn  {loc.  cit.,  p.  321)  and  Martins  {loc.  cit.,  p.  16)  assert  that  Fen- 
wick's  report  is  the  pioneer  observation  on  this  subject.  As  a 
matter  of  fact,  it  was  our  countryman,  Austin  Flint,  who  first  called 
attention  to  the  relation  between  anemia  and  atrophy  of  the  gastric 
gland  (Austin  Flint,  The  American  Medical  Times,  i860).  He 
expressed  the  opinion  that  some  cases  of  profound  anemia  are 
dependent  upon  atrophy  of  the  glands  of  the  stomach.  (The  fur- 
ther contributions  of  Flint  to  this  subject  are  to  be  found  in  the 
New  York  Med,  Jour,  for  March,  1871,  and  in  his  "  Principles  and 
Practice  of  Medicine,"  p.  477,  Philadelphia,  1881.)  The  priority 
of  Flint's  publications  have  been  emphasized  by  Professor  William 
H.  Welch  ("A  System  of  Medicine  by  American  Authors,"  vol.  11, 
p.  616).  Since  Flint's  publications,  cases  have  been  reported  by 
Quincke,  Brabazon,  Nothnagel,  Rosenheim,  and  G.  Meyer.  The 
purely  American  contributions  to  this  subject  are  very  valu- 
able. They  have  been  made  by  Henry  and  Osier  ("  Atrophy  of 
the  Stomach,  with  Clinical  Features  of  Progressive  Pernicious 
Anemia,"  Amer.  Jour.  Med.  Sciences,  April,  1887);  F.  P.  Kinnicutt 
("  Atrophy  of  the  Gastric  Tubules ;  Its  Relation  to  Pernicious 
Anemia,"  Amer.  Jonr.  Med.  Sciences,  vol.  xciv,  p.  419,  1887);  Allen 
Jones  ("Gastric  Anacidity,"  Nezu  York  Med.  Jour.,  p.  573,  May, 
1893);  D.  D.  Stewart  {Amer.  Jour.  Med.  Sciences,  Nov.,  1895); 
Einhorn  {Med.  Recoj-d,  June  11,  1892);  also  in  Boas'  Arc/iives  oj 
Digestive  Diseases, -voXviVat  \,  ^.  158.  Although  the  anemia  which 
supervenes  in  these  cases  of  achylia  can  not  be  directly  ascribed 
to  the  gastric  atrophy,  and  too  much  importance  was  attributed  by 
Flint  and  others  to  the  state  of  the  gastric  mucosa,  the  reports  of 
this  author  are,  nevertheless,  very  valuable,  because  the  secondary 
states,  which  we  have  mentioned  as  really  causing  the  anemia  and 
cachexia,  are  most  probably  brought  about  by,  and  owe  their 
origin  to,  the  primary  degenerative  changes  in  the  gastric  mucosa 
which  Flint  and  Osier  have  described. 

In  the  first  part  of  this  work  (pp.  129  to  135)  we  have  reported 
examinations  of  fragments  of  mucosa  derived  from  12  cases  of 
anacidity  or  subacidity  ;  of  these,  ten  were  cases  of  typical  achylia 
gastrica.  In  these  12  cases,  proliferation  of  glands,  with  marked 
round-cell  infiltration,  was  found  once.  The  fragment  was,  appar- 
ently normal  in  two  cases,  and  of  the  ten  cases  of  typical  achylia, 
granular  gastritis  and  atrophy  of  the  mucosa  could  be  established 


748  ACHYLIA    GASTRICA. 

in  nine.  In  making  the  diagnosis  of  simple  achylia  gastrica,  we 
excluded  all  those  cases  of  permanent  loss  of  secretion  evidently- 
due  to  carcinoma  or  pronounced  chronic  atrophic  gastritis.  In 
fact,  before  making  these  detailed  examinations,  we  supposed  it 
was  possible  that  this  form  of  achylia  existed  simply  as  a  neu- 
rosis, because  all  of  the  ten  cases  which  we  described  occurred 
in  neuropathic  patients.  We  had  also  inclined  to  Einhorn's  view, 
that  some  forms  of  achylia  might  be  of  purely  nervous  origin.  We 
have  since  then  examined  a  number  of  new  cases  in  addition  to 
those  reported,  making  in  all  14.  In  none  was  the  mucosa  found 
perfectly  normal.  It  seems  improbable  that  a  permanent  cessa- 
tion of  a  normal  function  could  be  caused  by  a  neurasthenic  con- 
dition. This  explanation  of  achylia  would  be  justifiable  only 
in  case  we  could  demonstrate  that  in  this  affection  the  gastric 
mucosa  was  perfectly  normal.  To  our  knowledge,  there  is  no  case 
of  well-authenticated  achylia  on  record  in  which  a  cure  or  an 
improvement  in  the  neurasthenia  was  reported  to  have  cured 
or  improved  the  secretory  defect.  The  question  has  also  sug- 
gested itself,  whether  achylia  gastrica  could  not  be  the  cause  of  the 
neurasthenia.  Nor  on  this  point  are  there  any  authenticated  obser- 
vations. Experience  has  taught,  however,  that  neurasthenic  dis- 
turbances disappear  in  these  cases  with  an  improvement  of  the 
general  condition,  while  the  achylia  continues,  which  would  not  be 
the  case  were  the  latter  the  cause  of  the  neurasthenia.  The  loss 
of  function  in  this  disease  is  not  a  relative  or  transient  one,  but  it  is 
absolute  and  permanent.  Biedert  {loc.  cit.,  p.  173)  gives  it  as  his 
opinion  that  the  persistent  loss  of  HCl  and  ferments  gives  the  im- 
pression of  a  lasting  defect,  not  of  a  variable  increasing  or  decreas- 
ing inhibition.  The  absence  of  the  gastric  secretion  is  the  same, 
whether  the  patients  are  very  much  run  down  and  emaciated  and 
subject  to  much  suffering  or  whether  they  are  in  a  state  of  good 
health.  The  supposition  of  Biedert,  that  there  may  be  a  great 
many  who  possess  this  defect  and  are  unaware  of  it,  has  been  veri- 
fied by  a  number  of  observations  among  the  students  at  our  clinic. 
During  our  studies  on  the  question,  whether  the  normal  healthy 
stomach  contained  digestive  juice  in  the  fasting  condition,  we  dis- 
covered an  athletic,  robust  student  who  had  no  HCl  whatever  in 
his  stomach,  whether  fasting  or  otherwise.  The  total  acidity,  taken 
after  test-meals  on  six  different  occasions,  varied  between  one  and 
four  ;  as  these  analyses  were  made  shortly  before  the  examinations 


SYMPTOMS    OF    ACHYLIA.  749 

for  the  degree  of  m.d.,  we  did  not  inform  the  candidate  of  the  physio- 
logical defect  in  his  stomach,  fearing  that  it  might  cause  him  some 
mental  annoyance,  and  for  all  that  we  know  he  may  still  be  unaware 
of  his  achylia  and  continue  in  vigorous  health.  Our  results  concern- 
ing the  condition  of  the  gastric  mucous  membrane  are  in  accordance 
with  those  of  Cohnheim  {loc.  cit),  Einhorn  [N.  Y.  Med.  Record, 
June  27,  1896),  Hayem  {Allgevi.  Wiener  vied.  Zeitimg,  1894,  Nr. 
2—17),  and  have  recently  been  supported  by  Martius  and  Lub- 
arsch  ("  Achylia  Gastrica,"  pp.  1 1 2  to  1 70).  The  results  of  the  very 
exact  investigations  of  these  last  authors  make  it  probable  that  a 
more  or  less  pronounced  granular  gastritis  exists  in  the  majority  of 
cases  of  achylia. 

The  anatomical  changes,  however,  are  not,  in  all  cases,  suffi- 
ciently advanced  to  explain  the  permanent  loss  of  function.  Excep- 
ting the  germicidal  power  of  HCl  in  the  gastric  secretion,  there  is 
no  indication  at  present  for  determining  whether  glandular  gas- 
tritis is  the  cause  or  result  of  achylia.  It  is  intelligible  that  a 
weak  gastric  parenchyma  should  be  less  resistant  to  exterior  detri- 
mental influences — such  as  bacterial  invasion — than  a  robust  gas- 
tric tissue. 

It  is  evident  from  what  has  been  said  in  the  etiology  of  the 
various  diseases  of  the  stomach  that  the  organ  is  exposed  to  many 
external  aggressions  of  a  thermic,  chemical,  mechanical,  and  bac- 
terial nature,  and  it  is  a  matter  of  astonishment  what  intense  mal- 
treatment a  healthy  stomach  will  endure  without  reacting  patho- 
logically. It  is,  therefore,  conceivable  that  the  anatomical  loss  of 
the  glandular  apparatus  will  render  those  individuals  afflicted  with 
primary  simple  achylia  more  susceptible  to  bacterial  invasion. 
Most  observers  agree  that  the  increased  vulnerability  of  the  mucosa 
goes  hand  in  hand  with  the  loss  of  secretion ;  this  lessens  the 
power  of  resistance,  and  eventually  induces  a  state  of  chronic 
granular  gastritis,  effected  by  causes  which  a  healthy  stomach 
would  resist  without  any  change. 

Synaptoms. — The  disturbances  of  function  may  long  remain 
latent.  Persons  with  achylia  may  have  no  subjective  or  objective  dis- 
turbances of  any  kind  ;  but  sooner  or  later  dyspeptic  complaints  arise. 
The  subjective  sensations  are  not  characteristic,  but  are  essentially 
those  of  nervous  dyspepsia,  accompanied  by  eructation,  fullness, 
and  pressure  after  eating,  gradually  leading  to  attacks  of  severe 
49 


750  ACHYLIA    GASTRICA. 

gastralgia.  The  symptomatology,  as  based  upon  the  complaints  of 
the  patient,  is  most  accentuated  in  neurasthenics.  In  persons  with 
a  perfectly  sound  nervous  system  achylia  may  exist,  and  the  indi- 
vidual may  be  unaware  of  it;  this  is  proven  by  the  case  of  the 
medical  student  reported  above.  Oppler  {De2itsc]ie  ined.  WocJienscJiv., 
1896,  Nr.  32,  S.  511)  has  reported  a  number  of  cases  which  make 
it  probable  that  loss  of  gastric  secretion  predisposes  to  diarrhea 
and  intestinal  catarrhs,  which  are  not  benefited  until  the  achylia 
is  discovered,  when  rational  treatment  effects  improvement.  The 
personal  description  which  Professor  Biedert  {loc.  cit)  gives  of  his 
own  case  is  a  weighty  argument  pointing  to  the  fact  that  achylic 
patients  are  very  much  predisposed  to  diarrhea.  Among  the  achylic 
patients  which  we  have  studied  (14  in  all),  we  observed  attacks  of 
diarrhea  in  five.  So  far  as  we  could  determine,  the  colon  and  the 
duodenum  were  in  a  normal  condition.  We  also  studied  the  state 
of  the  duodenum  by  our  method  of  duodenal  intubation,  showing 
the  pancreatic  and  hepatic  secretions  to  be  normal.  This  makes  it 
probable  that  these  diarrheas  are  possibly  not  due  to  an  extension 
of  the  anatomical  changes  in  the  stomach  to  the  intestine,  but  to 
fermentative  processes,  developed  in  the  absence  of  HCl  secretion. 
These  diarrheas  confirm  Bunge's  view  of  the  antiseptic  effect  of  the 
HCl  secretion. 

Martins'  conclusions  [loc,  cit.,  p.  loi)  are  the  following :  Achylia 
gastrica  is  due  to  two  conditions  :  (i)  A  primary  secretory  de- 
bility of  the  stomach,  constituting  simple  achylia  gastrica;  (2) 
atrophy  of  the  gastric  mucosa  (anadenia),  which  is  secondary 
achylia  gastrica.  The  primary  achylia  gastrica  is  either  congenital 
or  developed  on  the  basis  of  a  very  early  predisposition.  It  is 
associated  with  inherited  debility  of  the  nervous  system,  and  pre- 
vails among  so-called  neuropathic  patients. 

Primary  secretory  debility  of  the  stomach  is  an  individual 
peculiarity,  which  may  remain  latent  for  years,  and  without  demon- 
strable detriment  to  the  general  organism.  This  is  particularly 
the  case  when  the  motor  function  is  well  preserved,  and  the  motor, 
secretory,  and  resorptive  functions  of  the  intestine  continue 
normal. 

The  mucosa,  which  is  devoid  of  secretion,  exhibits  a  diminished 
vital  resistance  to  all  external  detrimental  influences.  This  explains 
the  fact  that  anatomical  alterations  of  varying  intensity  are  rarely 


PATHOLOGICAL  HISTOLOGY.  75  I 

absent  in  simple  achylia  gastrica.  The  structural  changes  bear  no 
proportionate  relation  to  the  absolute  gravity  of  the  loss  of 
function. 

It  is,  therefore,  probable  that  there  are  forms  of  so-called  atrophy 
of  the  gastric  mucosa  (the  primary  non-carcinomatous  anadenia) 
which  develop  preferably  on  the  basis  of  congenital  secretory  weak- 
ness of  the  stomach. 

Accordingly,  there  are  gradual  transitions,  clinically  and  anatomi- 
cally, from  congenital  simple  achylia  with  but  immaterial 
alterations  of  the  mucosa  to  achylia  with  chronic  granular 
gastritis  eventuating  in  complete  atrophy  of  the  secretory  mucosa. 

The  grave  results  for  the  total  organism  (progressive  anemia, 
malnutrition,  etc.)  which  have  been  ascribed  to  the  latter  type  do 
not  in  reality  develop  until  the  mucous  membrane  of  the  intestine 
is  extensively  involved  by  the   atrophy. 

Pathological  Histology. — The  investigations  made  by  the 
authors  quoted  in  the  literature  at  the  end  of  this  chapter  show  in 
general  a  marked  increase  in  the  interstitial  connective  tissue.  The 
surface  epithelium  contains  many  goblet  cells.  The  vestibules  to 
the  glandular  alveoli  are  very  tortuous,  and  so  dilated  that  they 
resemble  minute  cysts,  filled  with  homogeneous,  slightly  glandular 
masses,  that  stain  with  acid  anilin.  The  epithelial  cells  lining  the 
vestibules  present  marked  variations  in  structure  and  staining 
qualities.  Those  most  prominent  are  :  (i)  Ordinary  long  cylin- 
drical epithelial  cells.  (2)  Somewhat  shorter  cylindrical  cells  with 
dark  protoplasm  and  dark-staining  nucleus,  without  an  upper  end. 
(3)  Goblet  cells.  (4)  Cells  as  in  type  2,  but  with  a  very  dark  proto- 
plasm (Stohr  cells).  (5)  Cells  with  a  marked  fuchsinophilic  granula- 
tion. In  some  vestibules,  only  cells  answering  to  the  description  of 
type  2  are  found,  and  in  them  an  abundance  of  mitotic  figures.  In 
other  vestibules  we  find  goblet  cells  in  addition  to  these.  There 
are  very  few  vestibules  which   contain  normal  surface  epithelium. 

Among  the  other  characteristics  that  were  found  in  freshly  hard- 
ened stomachs  of  achylic  patients  are  :  (i)  Immigration  and  permea- 
tion of  leukocytes.  (2)  The  occurrence  of  mitoses  in  the  surface 
epithelium  and  in  that  lining  the  vestibular  alveoli.  (3)  Occurrence 
of  acidophilic  leukocytes.  (4)  Frequency  of  goblet  cells.  (5) 
Occurrence  of  so-called  Stohr's  and  Nussbaum's  cells.  (6)  Occur- 
rence of  hyaline  spheres. 

Referring  to  No.  1  of  the  above  observations,  it  should  be  stated 


752  ACHYLIA    GASTRICA. 

that  Sachs  ("  Zur  Kenntniss  d.  Magendriisen  b.  krankhaften 
Zustanden,"  Breslau,  iS86)  has  found  an  abundance  of  lymph-cells 
migrating  through  the  surface  epithelium  and  glandular  substance. 
The  pyloric  region  seems  to  be  more  invaded  than  any  other  part 
of  the  stomach.  Stintzing  considers  the  immigration  of  leukocytes 
in  the  normal  stomach  a  very  rare  occurrence.  Permeation  of  the 
gastric  mucosa  with  leukocytes  at  the  height  of  digestion  is  a 
normal  occurrence,  and  has  been  frequently  observed  in  animals. 
The  difference  in  the  achylic  stomach,  with  regard  to  the  permea- 
tion of  leukocytes,  is  simply  one  of  degree.  Lubarsch  found  that 
the  glandular  lumina  were  actually  packed  full  with  leukocytes,  and 
that  they  were  acidophilic  ;  this  property  has  not  been  found  in 
the  leukocytes  of  the  normal  stomach.  It  is  more  than  probable 
that  the  invasion  of  the  mucosa  with  acidophilic  leukocytes  to  such 
a  degree  as  Lubarsch  describes  is  pathological. 

Concerning  No.  2,  the  presence  of  mitoses  in  the  epithelia  of  the 
normal  stomach  is  denied  by  Sachs  {loc.  cii)  and  Oppel  ("  Lehrbuch 
der  vergleich.  mikroskop.  Anatomic  d.  Wirbelthiere,"  Bd.  i : 
Magen),  and  the  occurrence  of  karyokinetic  figures  in  the  chief 
and  border  cells  is  extremely  rare.  For  a  closer  study  of  the 
character  and  significance  of  the  mitotic  processes  we  refer  to  the 
literature  given  in  Dock's  article  under  the  diagnosis  of  gastric 
carcinoma  (p.  527).  The  hyaline  spheres  which  Lubarsch  describes 
are  composed  of  cell  granules  that  have  become  confluent  and  en- 
larged, but  are  still  contained  within  the  body  of  the  original  cell. 
These  hyaline  spheres  are  considered  pathognomonic  for  atrophic 
processes  in  the  gastric  mucosa. 

The  histological  changes  found  by  various  authors  in  achylia, 
and  which  we  have  been  enabled  to  confirm  in  cases  which  we 
had  opportunity  to  examine  at  autopsies  shortly  after  death,  in- 
dicate the  proliferation  of  the  interstitial  connective  tissue,  the 
occurrence  of  acidophilic  migrating  cells  ;  and,  in  addition,  the 
disappearance  of  the  specific  glandular  elements  and  cell  pro- 
liferation, emanating  from  the  vestibules  of  the  glands  ;  also  trans- 
formation of  the  gastric  mucosa  into  intestinal  mucosa.  The 
process  eventuates  in  complete  atrophy  of  the  mucosa.  Einhorn 
has  reported  a  case  of  achylia  in  which  a  bit  of  gastric  mucosa 
was  found  in  the  wash-water,  which  under  the  microscope  appeared 
normal.  We  obtained  normal  mucosa  from  two  cases  of  achylia, 
when     strips    were    cut    from    achylic     stomachs    running    from 


PROGRESSIVE    ATROPHIC    GASTRITIS    IN    ACHYLIA.  753 

the  esophagus  along  the  greater  curvature  to  the  duodenum  ;  on 
serial  sections  made  at  intervals  of  one  inch  apart,  small  districts 
of  microscopically  normal  mucosa  were  found,  particularly  near 
the  cardia,  while  most  other  portions  of  the  stomach  showed  distinct 
atrophic  changes,  with  profuse  immigration  of  leukocytes,  and 
proliferation  of  the  interstitial  connective  tissues.  A  small  bit  of 
mucosa  accidentally  found  in  the  wash-water  does  not  indicate  the 
state  of  the  entire  stomach.  When  such  normal  fragments  are  found 
in  achylia,  it  is  still  probable  that  portions  of  the  stomach  may  be 
diseased.  We  do  not,  therefore,  consider  the  evidence  satisfactory 
that  achylia  may  exist  with  a  perfectly  normal  gastric  histology. 

In  the  great  majority  of  cases  of  achylia,  a  progressive  atrophic 
gastritis  may  be  found  to  exist.  There  may  be  periods  in  the 
history  of  achylia  when  this  condition  exists  without  any  apparent 
alteration  in  the  gastric  mucous  membrane,  and  the  fact  that  most 
patients  do  not  consult  the  physician  until  the  process  has  de- 
veloped to  a  very  advanced  state,  may  explain  the  observation  that 
the  occurrence  of  achylia  with  perfectly  normal  stomachs  is  thus  far 
supported  by  very  few  reliable  microscopic  examinations  of  gastric 
tissue  fragments.  All  achylic  patients  give  a  history  of  years  of 
gastric  disturbances  when  they  first  present  themselves  for  treat- 
ment, the  anamnesis  thus  making  it  probable  that  the  gastric  changes 
must  have  progressed  very  far.  In  the  case  of  the  healthy  medical 
student  in  whom  we  found  achylia  on  six  different  examinations,  we 
did  not  succeed  in  obtaining  a  piece  of  the  gastric  mucosa.  In 
these  cases  frequent  examinations  for  fragments  of  mucosa  are 
necessary  to  decide  the  relation  between  the  histological  alteration 
and  the  clinical  history.  These  examinations  should  be  made  at 
frequent  and  regular  intervals,  and  in  case  of  autopsies  on  achylic 
patients  the  stomach  should  be  previously  preserved  by  pouring  in 
alcohol  or  Zenker's  fluid  within  a  half  hour  after  death,  so  as  to  pre- 
vent autodigestion.  What  relation  exists  between  the  atrophic 
process  of  the  intestines  and  that  of  the  stomach  is  unknown.  It 
may  be  a  direct  continuation  of  the  progressive  gastritis,  since  it  is 
very  probable  that  the  same  detrimental  agencies  that  cause  the  dis- 
ease of  the  stomach  give  rise  also  to  the  intestinal  atrophy.  One 
might  assume  also  that  excessive  demands  are  made  upon  the 
digestive  power  of  the  intestines  in  the  absence  of  the  preparatory 
digestive  function  of  the  stomach.  Again,  it  is  probable  that 
bacterial  fermentations  occur  to  a  much  greater  degree  when  the 


754 


ACHYLIA    GASTRICA. 


disinfecting  power  of  the  HCl  is  lost.  In  two  autopsies  on  subjects 
who  had  shown  the  symptoms  of  achyh'a,  the  author  observed  that 
the  coeliac  axis,  and  all  branches  arising  from  it,  were  of  unusually 
small  size.  The  gastric  arteries  were  smaller  than  those  of  normal 
stomachs.  The  intestinal  and  mesenteric  arteries  were  also  smaller 
in  diameter  than  normal.  The  dimensions  of  the  hepatic  and 
splenic  arteries  were  smaller.  The  arteries  of  the  heart  appeared 
normal  in  size. 

Etiology. — Aside  from  the  probabilit)'-  that  achylia  may  be 
either  congenital  or  developed  upon  a  neuropathic  basis,  not  much 
is  known  of  the  causation  of  the  progressive  atrophic  gastritis. 
It  has  been  supposed  that  bacterial  infection  is  an  etiological 
factor  in  bringing  about  this  state  of  the  mucosa.  We  may  con- 
ceive the  bacterial  invasion  to  have  occurred  in  a  similar  manner 
to  that  pictured  under  the  head  of  ulcus  carcinomatosum.  In  one 
of  our  drawings  the  presence  of  bacilli  is  represented  beneath 
the  floor  of  the  ulcer,  some  of  them  located  in  the  muscularis. 
(Plate  VIII  and  Fig.  38,  p.  497.)  It  is  not  known  whether  this  bac- 
terial invasion  is  a  cause  or  a  result  of  these  processes.  Syphilis 
and  tuberculosis  may  be  predisposing  factors. 

Example  of  CImical  History. — Mr.  L.  W.,  thirty-two  years  old,  reporter  on 
a  daily  newspaper.  Up  to  1894  he  was  physically  well  and  in  good  health, 
although  he  admits  to  have  frequently  abused  his  stomach  by  overeating  and 
overdrinking.  His  mother  is  a  highly  neurasthenic  woman  who  imagines  she 
is  afflicted  with  all  sorts  of  ailments  ;  father  high-strung  and  arbitrary.  His 
duties  necessitate  that  he  should  be  awake  during  the  night  and  sleep  during 
the  day.  As  a  consequence  of  this,  he  is  compelled  to  take  his  meals  at  very 
irregular  hours.  He  frequently  does  not  obtain  sufficient  sleep,  being  awak- 
ened by  noises  in  the  street  (trolley  cars,  etc.)  and  about  the  house  in  which  he 
lives.  He  usually  gets  to  bed  about  five  o'clock  in  the  morning,  and,  if  his 
nerves  are  quiet,  sleeps  until  eleven  or  twelve;  then,  arising,  he  takes  his  break- 
fast. His  main  meal  is  taken  between  five  and  six  o'clock  in  the  afternoon. 
At  seven  o'clock  he  must  report  for  duty  as  night  clerk  or  reporter  of  the  Asso- 
ciated Press.  The  work  he  has  to  perform  is  frequently  of  an  exciting  and 
enervating  character.  During  the  summer  of  1894,  while  it  was  very  hot,  he  had 
indulged  in  very  cold  beer  during  the  night  while  following  up  some  sporting 
occasion,  and  since  then  has  suffered  from  dyspepsia,  nausea,  eructation,  etc. 
Sometimes,  after  a  meal,  he  will  be  attacked  with  palpitation  of  the  heart  and 
a  feeling  of  giddiness,  which  has  recently  been  associated  with  sensations  of 
precordial  fear.  His  appetite  in  the  summer  of  1895  was  very  poor  ;  the  food 
was  described  as  weighing  down  his  stomach  like  a  lump  of  lead.  Heart  pal- 
pitation so  strong  that  he  can  not  sleep  because  of  the  noise  his  heart  makes. 
In  one  month  of  the  summer  of  1895  he  lost  11  pounds. 


TREATMENT    OF    ACHYLIA    GASTRICA.  755 

Analysis  of  Test-meal. — The  first  test-meal,  which  was  the  one  used  by  us 
and  described  on  page  iii,  had  disappeared  from  the  stomach  entirely 
fifty-five  minutes  after  it  had  been  eaten.  The  second  test-meal  was  drawn 
fifty  minutes  after  it  had  been  taken ;  the  amount  was  about  three  ounces, 
and  it  consisted  of  chewed  particles  of  wheat  bread  entirely  unchanged.  Total 
acidity  =  5 ;  free  HCl,  negative;  combined  HCl,  negative;  lactic  acid, 
trace;  propeptone  and  peptone,  absent.  On  test  by  milk  digestion,  rennin  and 
renninzymogen,  absent;  pepsinogen,  absent;  very  slight  quantity  of  mucus; 
very  slight  amount  of  filtrate  gained  by  pressing  the  drawn  ingesta  through  a 
sieve.  Test  of  motor  function,  by  the  Hemmeter  method,  shows  a  rather  in- 
creased peristalsis. 

Absorption  (Penzoldt  and  Faber's  method)  is  abnormally  delayed.  Exam- 
ination of  a  fragment  of  mucosa  shows  irregular  dilatations  of  the  peptic 
gland-ducts ;  there  is  some  increase  of  the  interglandular  connective  tissue, 
which  is  infiltrated  with  tremendous  numbers  of  leukocytes,  which  have  also 
pervaded  the  epithelial  cells  of  the  vestibules.  Here  and  there  the  entire  lumen 
of  the  gland-duct  is  packed  full,  and  apparently  pushed  apart  with  an  enormous 
invasion  of  lymphoid  cells.  The  characteristic  spindle-shaped  connective- 
tissue  cells  are  present,  but  unless  carefully  soughf  for  they  escape  detection, 
on  account  of  a  copious,  round-cell  infiltration,  and  of  the  invasion  of  leuko- 
cytes, to  which  reference  has  been  made.  Many  eosinphilic  cells  present.  In 
the  epithelia,  numerous  chromosomes  and  cells  containing  more  than  one 
nucleus.  The  neuclei  in  these  cells  are  in  various  stages  of  indirect  division, 
showing  atypical  figures. 

Anatomical  diagnosis,  chronic  granular  gastritis.  This  patient  improved 
very  much  after  a  vacation  of  six  weeks  in  the  summer,  which  brought  him  the 
necessary  sleep  at  night  and  rest.  Remedies  to  restore  HCl  secretion  have  been 
tried  persistently  for  one  year  and  six  months  without  effect.  He  repeatedly 
suffered  in  the  hot  season  of  the  year  from  attacks  of  diarrhea,  which  were 
easily  controlled  by  administering  HCl  and  subnitrate  of  bismuth,  together 
with  a  proper  diet.  The  patient  has  relapses  whenever  he  indulges  in  over- 
work, with  loss  of  sleep.  Since  1895,  23  test-meal  analyses  have  been  made, 
not  one  showing  a  trace  of  HCl  or  ferments. 

Treatment. — We  are  in  the  habit  of  prescribing  dilute  HCl  for 
all  these  cases  whenever  the  acid  agrees  well.  As  considerable 
HCl  is  needed  to  effect  any  appreciable  digestive  action  and  to 
exert  a  disinfecting  influence,  we  give  20  drops  of  the  officinal 
dilute  HCl  every  half  hour  after  meals  until  60  drops  have  been 
taken.  The  acid  must  be  largely  diluted  and  taken  through 
a  glass  tube.  Our  experience,  which  is  based  upon  a  large  number 
of  cases  of  this  sort,  has  convinced  us  that  the  acid  is  not  only  well 
tolerated,  but  is  almost  indispensable  to  the  patient.  Although  it 
may  be  argued  that  achylic  patients  sometimes  get  along  without 
any  treatment  whatever,  simply  because  they  exhibit  no  symptoms, 
nevertheless  when   they    do   apply  for   treatment    they  generally 


756  ACHYLIA    GASTRICA. 

present  a  complexity  of  symptoms,  which  are  much  benefited  by 
carefully  selected  but  nutritious  diet,  sometimes  rest  in  bed,  strych- 
nin, and  HCl.  When  the  appetite  is  absolutely  lost,  it  may  be 
restored  by  washing  out  the  stomach  with  bitter  tonics,  such 
as  gentian  and  quassia.  In  neurasthenic  patients,  strychnin  sul- 
phate improves  not  only  the  local  gastric  symptoms,  but  also 
the  symptoms  of  the  general  neurasthenia.  A  number  of  gastric 
patients  of  this  kind  refuse  to  eat,  because  they  fear  that  distress 
will  be  caused  by  the  food.  In  such  cases  it  may  become  neces- 
sary to  place  the  patient  in  a  well-managed  institution  for  the 
dietetic  treatment  of  digestive  diseases.  They  must  gradually  be 
convinced  that  food  that  is  ingested  with  appetite  can  do  no  harm. 
When  the  motility  is  interfered  with  and  symptoms  of  dilatation 
are  manifest,  gastric  lavage  is  indispensable.  Concerning  the  use 
of  pepsin  and  pancreatin  see  pp.  331,  332. 

Diet. — The  achylic  patient  is  an  individual  who  has  an  internal 
infirmity,  due  either  to  a  congenital  defect,  or  to  an  acquired 
irregularity  in  the  gastric  structure.  Whatever  may  be  the  condi- 
tion and  the  cause,  we  are  dealing  with  individuals  who  are  essen- 
tially weak  and  debilitated.  We  have  found  it  expedient  not  to  be 
too  exacting  with  diet  orders.  In  fact,  we  make  it  a  rule  never  to 
give  a  standing  diet  order  to  an  achylic  patient  without  carefully 
inquiring  as  to  the  food  which  he  knows  from  experience  agrees 
best  with  him.  The  stomach  is  a  protective  and  selective  organ, 
preparing  the  food  for  the  intestines.  By  its  selective  prop- 
erty, when  the  motility  is  in  a  normal  condition,  it  permits  only 
the  semisolid  and  liquid  masses  to  pass  first,  while  the  more 
consistent  masses  are  retained  to  be  further  softened  and  disinte- 
grated. We  have  shown,  in  the  preceding  pages,  that  the  stomach 
of  the  achylic  patient  has  lost  the  power  to  dilute  its  contents  by  a 
secretion  from  its  walls.  This  is  one  of  the  main  reasons  why  we 
permit  the  ingestion  of  liquids  during  meals,  and  of  largely  diluted 
HCl  after  meals.  For  the  same  reason  all  foods  should  be  well 
chewed,  or  preferably  finely  divided  during  the  process  of  cooking, 
for  the  main  object  of  all  treatment  must  be  to  preserve  the  peris- 
talsis, and  to  insure  a  healthy  state  of  the  mucosa.  Therefore, 
the  food  should  generally  be  taken  in  form  of  gruels,  pastes,  or 
in  any  semisolid,  easily  swallowed  state.  The  meat  should  be  very 
soft, — scraped  or  run  through  the  meat-chopper.  Fish,  sweet- 
bread, calf's  brain,  and  soft-boiled  eggs  are,  as  a  rule,  of  such  soft 


DIETETIC    TREATMENT    OF    ACHYLIA    GASTRICA.  757 

consistency  that  they  need  no  further  preparation.  Our  experience 
is  that  the  more  food  is  ingested  and  well  tolerated,  the  better  for 
the  patient  in  these  cases.  We  will  give  no  outline  here  of  detailed 
diet  list,  but  refer  the  reader  to  the  diet  order  for  anacidity  and 
Penzoldt  graded  diet  order  given  in  the  chapter  on  Dietetics.  In 
many  cases,  physical  and  mental  rest,  hygienic  surroundings,  and  a 
nourishing  diet  will  be  all  that  is  needed  for  insuring  comparative 
well  being  of  the  patients.  Where  the  motor  power  becomes 
defective,  the  treatment  will  be  that  outlined  in  the  chapter  on 
Motor  Insufficiency. 

A  remedy  little  known — but  a  very  valuable  adjuvant  in  treat- 
ment for  lack  of  dietetic  ferment — is  the  juice  of  fresh  pineapple. 
This  has  decided  proteolytic  power,  and,  besides,  is  a  pleasant, 
easily-procured  remedy. 

There  is  no  treatment  that  is  universally  applicable  to  all  cases 
of  achylia.  The  ability  of  the  practitioner  in  discerning  the  special 
indications  for  each  individual  case  is  put  to  the  test  severely  in 
the  therapeutic  management  of  this  disease.  Sometimes  the  treat- 
ment will  be  that  of  chronic  gastritis,  sometimes  that  of  nervous 
dyspepsia.  Excessive  strictness  in  dietetic  regulation  has,  in  the 
author's  opinion,  occasionally  developed  gastric  "  hypochondriacs." 
It  is  more  advisable  to  train  up,  or,  as  Broadbent  says,  "  level  up,"  the 
gastric  digestion  to  a  higher  plane.  We  make  it  a  rule  to  show  these 
gastrophobic  patients  the  contents  of  their  stomachs  at  a  proper 
time  after  full  meals,  to  convince  them  that  they  can  digest  thor- 
oughly, for,  as  a  rule,  every  vestige  of  food  will  have  passed  out 
of  the  organ  within  one  and  one-half  hours. 

The  literature  on  achylia  gastrica  will  be  found  compiled  in  the 
article  by  Martins  and  Lubarsch,  published  by  Franz  Deuticke, 
Leipzig,  1897. 


CHAPTER  XIII. 

NERVOUS  DYSPEPSIA  (Leube).— NEURASTHENIA 
GASTRICA  (Ewald). 

The  original  definition  which  Leube  gave  of  this  affection  char- 
acterized it  as  a  neurosis  of  sensibility,  without  any  well-defined 
and  constant  objective  disturbances  of  digestion,  but  exhibiting  a 
large  variety  of  subjective  symptoms  connected  with  the  digestive 
act  and  occurring  independently  of  any  demonstrable  changes  in 
the  stomach. 

In  his  first  paper,  Leube  ("  Ueber  nervose  Dyspepsie,"  DeiitscJi. 
Arch.f.  klin.  Med.,  Bd.  xxrii,  1879)  emphasized  that  the  gastric  diges- 
tion may  be  perfectly  normal  so  far  as  the  chemistry  and  motility 
are  concerned,  and  that  he  has  used  the  term  "  dyspepsia,"  or  diffi- 
cult digestion,  because  this  act  is  accompanied  by  manifold  com- 
plaints that  are  traceable  to  an  abnormal  excitability  of  the  sensory 
gastric  nerves.  Since  then  Leube  has  expanded  the  conception 
of  nervous  dyspepsia  to  the  effect  that  it  includes  anomalies  of 
secretion  and  motility. 

R.  Geigel  and  Abend  (pupils  of  Leube)  later  on  demonstrated 
that  the  secretion  of  HCl  may  be  extremely  variable  in  nervous 
dyspepsia,  and  that  we  may  have  a  normal  acidity,  or  euchlorhydria, 
subacidity,  anacidity  or  achylia,  or  hyperacidity.  Accordingly, 
the  important  symptoms  of  the  trouble,  viz.,  the  annoying  gastric 
distress,  can  not  be  traced  to  fermentations  of  the  gastric  contents 
with  sub-  or  inacidity,  or  to  the  products  of  this  decom- 
position, nor  to  irritation  of  the  gastric  nerves  in  super- 
acidity.  It  is  natural  that  the  definitions  and  conceptions  of 
various  authors  concerning  a  disease  that  is  so  vague  and  in- 
definite in  its  clinical  history  and  pathology,  should  differ  greatly. 
Leube  distinguishes  more  recently  between  two  kinds  of  nervous 
dyspepsias  :  {a)  Nervous  dyspeptic  symptoms  in  which  the  ner- 
vous channels  are  sympathetically  involved  by  anatomical  changes 
in  the  stomach,  and  altered  chemistry  of  digestion  caused  by 
these  changes.     (/;)  Nervous  dyspepsia  with  an  apparently  normal 

758 


PATHOLOGY    AND    ETIOLOGY    OF    NERVOUS     DYSPEPSIA.  759 

anatomical  state  of  the  organ.  Boas  distinguishes  a  third  form  of 
nervous  dyspepsia,  which  originates  reflexlyfrom  other  organs  ;  for 
instance,  the  kidneys,  uterus,  ovaries,  male  genito-urinary  appa- 
ratus, and  intestine.  Constitutional  diseases,  such  as  tuberculosis, 
syphilis,  diabetes  mellitus,  anemia,  uric  acid  diathesis,  may  form  the 
basis  of  this  complexity  of  symptoms.  The  disease  may  occur  in 
an  idiopathic  form,  independently  of  any  demonstrable  gastric 
changes,  or  in  a  secondary  form  consequent  upon  neurasthenia, 
hysteria,  and  the  other  pathological  states  referred  to.  Whatever 
the  underlying  basis  or  etiology  of  the  disease,  the  ultimate  symp- 
toms can  be  described  to  a  functional  sensory  neurosis  and  overexcita- 
bility  of  the  gastric  nerves,  which  may  become  so  acute  that  they 
react  in  a  pathological  manner  upon  the  influence  of  normal  diges- 
tive stimulation. 

Pathology. — Jiirgens  has  discovered  total  degeneration  of  the 
plexus  of  Meissner  and  Auerbach  in  41  cases  of  nervous  dyspep- 
sia. In  one  of  the  cases  in  which  the  sensory  disturbances  were 
predominant,  and  the  intestinal  functions  involved  also,  this  author 
found  a  distinct  degeneration  of  the  muscularis  of  the  stomach  and 
intestine.  Further  exact  pathological  and  histological  investiga- 
tion will  very  probabh'  restrict  the  number  of  cases  at  present 
classed  under  nervous  dyspepsia.  The  conceptions  of  various 
authors  concerning  the  nature  of  nervous  dyspepsia  vary  consid- 
erably. Leube,  as  is  well  known,  states  that  nervous  dyspepsia  is 
of  central  origin,  while  Stiller  applies  the  name  to  all  digestive  dis- 
turbances that  are  transmitted  to  the  stomach  through  the  central 
or  the  sympathetic  nervous  system.  Stiller  attributes  greater  import- 
ance than  Leube  to  disturbances  of  the  secretory  function,  which  he 
could  demonstrate  in  a  majority  of  his  cases.  We  interpret  the 
disease  as  a  mixed  neurosis,  in  which  the  motor  secretory  and  sen- 
sory nerve  apparatus  are  affected  contemporaneously  or  alternately  ; 
an  anatomical  substratum  is  present  in  one-half  of  the  cases,  but  it 
is  not  of  a  constant  type. 

Etiology. — Neurasthenia  gastrica  has  been  observed  after  intense 
emotional  excitement,  exhaustive  mental  work,  alcoholic  and 
sexual  excesses,  after  abuse  of  tobacco,  and  associated  with  pul- 
monary phthisis,  nephritis,  and  malaria.  The  sensibility  of  the 
normal  gastric  mucosa  is  very  slight,  and  the  digestive  irritation 
causes  no  distinct  sensation  in  the  normal  individual,  but  when  a 
healthy  person  transgresses  the  customary  amount  of  food,  unpleas- 


760  NERVOUS    DYSPEPSIA. 

ant  sensations  of  pressure,  distention,  fullness,  eructation,  and 
nausea  will  ensue,  indicating  that  the  organ  has  been  overloaded. 
These  sensations  cease  when  a  part  of  the  chyme  has  passed  out 
into  the  intestine. 

Narcotic  substances,  such  as  very  strong  coffee,  tea,  or  tobacco 
may  relieve  or  remove  these  symptoms,  showing  that  they  are  of 
a  purely  nervous  character.  If  the  excitability  of  the  sensory 
nerves  is  for  any  reason  increased,  then  the  normal  digestive  irrita- 
tion brings  about  such  gastric  difficulty.  With  an  intensely  excit- 
able nervous  apparatus  in  the  stomach,  such  symptoms  as  we  have 
described  may  come  on  e\'en  when  the  organ  is  empty.  It  is  char- 
acteristic of  nervous  dyspepsia  that  gastric  distress  is  perceived 
only  after  meals,  and  is  absent  when  the  stomach  is  empty.  The 
nervous  dyspepsia  associated  Avith  malaria  should  induce  the  physi- 
cian to  examine  the  blood  of  the  patient  for  the  malarial  parasite. 
The  symptoms  in  these  cases  generally  abate  under  the  influence 
of  quinin. 

As  a  secondary  neurosis,  neurasthenia  gastrica  is  generally  the 
result  of  general  neurasthenia  or  hysteria.  Grave  anatomical  altera- 
tions of  the  brain  and  spinal  cord,  which  frequenth*  bring  on  other 
gastric  neuroses,  are,  so  far  as  we  know,  not  reported  to  have  any 
causal  relation  to  nervous  dyspepsia. 

Reflexly,  the  disease  may  result  from  irritation  arising  from  the 
genito-urinary  organs  in  both  sexes,  from  menstrual  and  puerperal 
disturbances.  The  dyspepsia  during  the  puerperal  period  has 
been  attributed  to  traction  or  compression  of  the  sympathetic. 
In  a  portion  of  the  cases  it  is  impossible  to  attribute  any  cause. 
It  is  a  disease  which  prevails  among  the  male  sex. 

Symptomatology. — The  clinical  picture  of  neurasthenia  gas- 
trica is  extremely  variable.  It  is,  therefore,  impossible  to  give  a 
well-defined  typical  representation  of  the  disease  that  can  be 
applicable  to  the  majority  of  the  cases.  We  will,  therefore,  simply 
designate  the  most  important  and  frequent  s}-mptoms.  It  is  char- 
acteristic of  nervous  dyspepsia  that  the  gastric  distress  is  directly 
dependent  upon  the  ingestion  of  food — that  it  occurs  only  after 
meals,  and  not  on  an  empty  stomach. 

Furthermore,  it  is  characteristic  that  the  quality  and  the  quantity 
of  the  food  and  dietetic  errors  exert  no  influence  upon  dyspepsia. 
At  times  the  most  indigestible  food  causes  no  difficulty  whatever, 
and  at  other   times  the    most  digestible   food    brines   on  distress. 


SYMPTOMATOLOGY    OF    NERVOUS    DYSPEPSIA.  76 1 

The  sensations  of  the  patient  are  very  much  under  the  influence 
of  the  emotional  state.  The  dyspeptic  symptoms  are  :  Unpleasant 
sensations,  pressure,  fullness,  distention  of  the  stomach,  occurring 
shortly  after  meals.  After  the  patients  have  slept  well,  they  are  in 
a  cheerful  state  of  mind  in  the  morning,  but  immediately  after 
breakfast  they  are  tormented  by  manifold  sensations  in  the 
stomach.  The  suffering  is  most  severe  when  the  neurasthenia 
gastrica  is  accompanied  by  hyperacidity.  In  this  case  it  increases 
during  the  second  period  of  digestion  as  the  acidity  becomes 
greater.  Such  types  are  relieved  by  the  administration  of  alkalies, 
which,  however,  are  useless  with  achylia.  The  epigastric  region  is 
not  very  sensitive,  nor  are  there  any  characteristic  pain-points,  so 
far  as  we  could  determine. 

Leven  ("  Estomac  et  Carvau,"  Paris,  1884)  attributes  great  im- 
portance to  the  appearance  of  these  so-called  painful  spots,  which 
are  supposed  to  be  due  to  an  irritation  of  the  solar  plexus. 
Burkhart  ("  Pathol,  der  Neurasthenia  Gastrica,"  Bonn,  1882), 
Fleischer,  Ewald,  Bouveret,  and  Richter  do  not  attribute  much 
importance  to  this  symptom.  In  some  cases  very  peculiar  sensa- 
tions are  described  by  these  patients.  Some  have  a  crawling  feeling 
in  the  stomach,  as  if  some  live  animal  were  moving  about  in  it. 
Some  have  a  sensation  of  tickling,  others  describe  it  as  a  beating, 
burning,  or  sticking  sensation.  A  most  unusual  sensation  is  that 
described  as  a  restless,  wavy,  or  undulating  motion.  Persistent 
eructation  is  a  very  frequent  and  annoying  symptom.  The  eruc- 
tations occur  in  an  explosive  manner,  and  without  any  regard  for 
the  surroundings.  If  there  is  hyperacidity,  these  eructations  are 
accompanied  by  severe  pyrosis.  Emesis  is  rare,  but  when  it  does 
occur  the  character  and  consistency  of  the  vomit  depends  upon 
the  composition  of  the  gastric  juice.  With  normal  acidity  or  hyper- 
acidity it  has  a  very  sour  taste  and  is  void  of  proteid  food  when 
the  acid  is  present  in  excess.  With  subacidity  or  inacidity,  it 
contains  much  undigested  meat  and  eggs  and  but  little  carbohy- 
drate food.  Although  inacidity  may  be  present,  the  gastric  con- 
tents do  not  decompose  because  there  is  no  stagnation.  The  appe- 
tite is  variable.  There  may  be  a  normal  appetite,  bulimia,  or 
anorexia.  As  a  rule,  thirst  is  increased.  The  behavior  of  the 
sensory  gastric  nerves  is  capricious.  When  the  patient  is  in  a 
cheerful,  pleasant  humor,  or  occupied  with  a  congenial,  interesting 
piece  of  work,  he  will  digest  articles  of  diet  which  will    cause  very 


762  NERVOUS    DYSPEPSIA. 

great  distress  when  he  is  emotionally  depressed.  Excessive  men- 
tal or  bodily  work,  cares  and  worries  concerning  the  vocation, 
disappointments  in  business  enterprises,  grief,  etc.,  all  cause  a  con- 
dition of  excitability  in  which  digestion  is  much  impaired. 

Secretory  Function. — In  neurasthenia  gastrica  there  may  be  a 
normal  secretion,  hyperacidity,  or  inacidity.  When  in^cidity  exists 
the  ferments  can  still  be  demonstrated  in  the  gastric  contents. 
This  important  fact  will  serve  to  distinguish  this  type  of  nervous 
dyspepsia  from  typical  achylia  gastrica. 

Motor  Function. — The  peristalsis  of  the  stomach  is  undisturbed  in 
neurasthenia  gastrica. 

Intestinal  Disturbances. — The  most  constant  symptom  is  obstinate 
constipation.  Very  frequently  there  are  rumbling  noises  in  the 
intestines  and  extensive  flatulence. 

Nervous  Symptoms. — These  consist  of  pain  and  pressure  in  the 
head,  giddiness,  tinnitus  aurium,  flashes  before  the  eyes,  rapid 
pulse,  exhaustion,  cool  extremities,  attacks  of  fainting,  palpitations 
of  the  heart,  dyspnea.  It  is  very  probable  that  all  these  symptoms 
are  connected  with  the  deranged  intestinal  digestion,  and  that  they 
are  due  to  the  absorption  of  toxic  products  formed  during  the 
putrefaction  of  food  in  the  intestines.  C.  A.  Herter  and  E.  E. 
Smith  {N.  Y.  Med.  Joiir.,  June  22  and  29,  July  6,  13,  and  20, 
1895)  have  published  clinical  histories  and  detailed  analyses  show- 
ing the  relations  of  psychic  disturbances,  melancholia,  etc.,  to  the 
toxicity  of  the  urine.  There  is  no  doubt  that  the  production  of 
these  symptoms,  particularly  frontal  headache,  beating  in  the  head, 
congestions,  pulsations  of  the  large  arteries,  globus  hystericus,  mel- 
ancholia, and  insomnia,  is  in  some  way  related  to  excessive  intesti- 
nal putrefaction.  When  the  nervous  dyspepsia  is  comparatively 
recent,  the  symptoms  are  limited  to  the  gastro-intestinal  tract,  but 
when  the  disease  is  of  long  standing,  the  nervous  symptoms  may 
submerge  the  digestive,  and  it  may  be  difiicult  to  decide  whether 
the  latter  or  the  former  constitute  the  primary  derangement. 

Prognosis. — Inasmuch  as  the  course  of  the  disease  is  a  chronic 
one,  it  may,  in  severe  cases,  by  continued  and  progressive  loss  of 
strength  and  emaciation,  prove  fatal.  In  those  cases  in  which  a 
cure  has  been  effected  relapses  may  occur,  so  that  the  prognosis 
should  be  guarded.  Sometimes,  when  the  fundamental  disease  is 
remediable,  for  instance,  in  genito-urinary  disturbances,  malaria, 
etc.,  or  when  the  cause,  such  as  sexual  excesses,  abuse  of  alcohol 


HETEROCHYLIA.  763 

and  tobacco,  bodily  and  mental  overexertion,  can  be  removed,  the 
resulting  nervous  dyspepsia  may  be  permanently  cured. 

Diagnosis. — As  a  general  rule,  it  will  be  found  that  the  nervous 
dyspepsia  is  connected  with  some  organic  disease  of  one  of  the 
digestive  organs.  We  refer  to  the  various  anomalies  of  position 
of  the  intra-abdominal  organs  that  are  described  in  the  chapter  on 
Gastroptosis  and  Enteroptosis.  Frequently,  dislocated  kidneys, 
small  tumors,  herniae  of  the  median  linea  alba,  morbid  changes  in 
the  male  or  female  sexual  organs,  and  organic  diseases  of  the 
stomach  and  intestines,  will  be  found  to  exist.  There  will  be  no 
connection  between  the  quality  and  quantity  of  the  food  and  the 
digestive  difficulties,  but  sleep,  emotional  state,  and  psychic  con- 
dition will  be  influential  factors.  The  complaints  of  the  patient  are 
frequently  described  in  exaggerated  language.  One  of  our  patients, 
who  is  the  owner  of  a  brickyard,  describes  his  feelings  "  as  similar 
to  the  rolling  of  a  ton  of  bricks  in  his  belly  "  ;  another  compares 
his  sensation  to  being  "  stabbed  with  a  red-hot  knife  "  ;  still  another 
describes  her  abdomen  as  being  "  distended  to  bursting,  like  a  bal- 
loon," or,  at  other  times,  as  feeling  compressed  as  though  it  were 
in  a  vise.  At  other  times  these  same  patients,  without  recognizable 
reason,  will  make  no  complaints  at  all,  will  be  very  happy  and  cheer- 
ful, and  digest  well.  These  variations  in  the  functional  powers  of 
digestion  are  very  characteristic  of  nervous  dyspepsia.  Leube  has 
called  our  attention  to  the  emptiness  of  the  stomach  seven  hours 
after  a  rather  heavy  test-meal. 

Heterochylia  (from  irepoq,  meaning  "  other  "  or  "  different,"  and 
yuU<;,  meaning  "juice  "  or  "secretion"). — This  term  is  suggested 
by  the  author  to  denote  a  rapidly-alternating  state  of  secretion, 
occurring  chiefly  in  nervous  dyspepsia.  In  making  a  large  num- 
ber of  analyses  in  these  cases.  Dr.  E.  L.  Whitney  and  the  author 
have  observed  within  one  week  that  euchlorhydria,  hyperchlor- 
hydria,  and  inacidity  will  be  found  after  the  same  test-meals.  In 
the  discussion  of  a  paper  read  before  the  American  Medical 
Association,  in  Philadelphia,  June  4,  1897,  a  colleague,  Dr.  E.,  of 
Brooklyn,  stated  that  in  his  own  case  he  had  observed  hyper- 
acidity and  inacidity  on  the  same  day,  after  he  had  taken  the 
identical  meals  and  drawn  a  sample  within  one  hour  after  they 
had  been  ingested.  Dr.  E.,  who  is  an  able  chemist,  made 
quantitative  analyses  of  his  gastric  juice  on  many  occasions, 
and,  so  far  as  he   can   tell,  these  variations   in   the  secretion  are 


764  NERVOUS    DYSPEPSIA. 

independent  of  his  emotional  state.  In  a  number  of  the  cases 
examined  by  Dr.  Whitney  and  the  author  they  found  hyperacidity 
with  rapid  digestion  of  proteids,  and  defective  carbohydrate  diges- 
tion with  symptoms  of  pyrosis  and  eructation  that  were  relieved 
by  alkalies.  Two  days  afterward,  the  author  examined  the  same 
cases,  to  find  that  two  of  them  showed  no  reaction  with  Congo 
paper  and  a  pronounced  HCl  deficit.  There  was  no  pyrosis  nor 
eructation,  but  the  patients  complained  of  a  sense  of  fullness  and 
weight  in  the  stomach,  together  with  anorexia,  which  symptoms 
were  relieved  by  two  doses  of  dilute  HCl  (30  drops  per  dose). 
At  the  end  of  this  week  we  had  occasion  to  examine  the  same 
cases  again,  and  found  the  acidity  normal.  For  want  of  a  better 
expression  we  have  designated  these  rapidly  alternating  states  of 
secretion  by  the  name  heterochylia.  When  the  acid  is  in  excess,  the 
proteids  are  absent  from  the  test-meals,  and  rice  and  bread 
almost  undigested.  When  the  acid  is  absent,  one  may  frequently 
find  a  defective  proteid  digestion  but  a  rapid  carbohydrate  diges- 
tion. We  have  no  explanation  to  offer  for  these  cases  beyond 
those  which  are  purely  hypothetical,  but  it  is  conceivable  that 
a  closer  histological  study  of  the  finer  ramifications  of  the  gastric 
nerves,  such  as  has  been  carried  out  with  such  admirable  regard 
for  detail  by  Henry  J.  Berkley  in  other  organs  of  the  body, 
may  throw  some  light  upon  this  puzzling  phenomenon.  For 
instance,  we  may  sooner  or  later  be  instructed  that  the  oxN^tic 
or  border  cells  receive  a  different  nervous  supply  from  the  chief 
or  central  cells,  or  that  both  chief  and  border  cells  are  supplied 
by  nerves  of  widely  differing  character,  one  set  exciting  the 
function,  the  other  inhibiting  it;  i.  e.,  anabolic  and  catabolic  secre- 
tory fibers;  but  all  this  is  premature  and  problematical. 

Differential  Diagnosis. — Nervous  dyspepsia  v»'ith  inacidity  may 
be  confounded  with  chronic  gastritis  or  carcinoma,  and  nervous 
dyspepsia  with  hyperacidity  may  be  confounded  with  ulcer,  while 
still  other  forms  may  bear  a  striking  resemblance  to  atony  or 
myasthenia.  For  the  separation  of  chronic  gastritis  from  nervous 
dyspepsia,  the  following  facts  are  of  importance :  Chronic  gastritis  is 
accompanied  more  frequently  by  vomiting ;  the  stomach  contains 
large  quantities  of  mucus  and  a  few  blood  streaks ;  we  may  have 
also  stagnation  of  the  contents.  The  course  of  chronic  gastritis  is 
more  uniform  and  typical,  and  the  dyspeptic  symptoms  are  directly 
influenced  by  the  quality  and  quantity  of  the  ingesta.     In  carci- 


DIAGNOSIS    AND    TREATMENT    OF    NERVOUS    DYSPEPSIA.  765 

noma,  the  distress  is  present  at  all  times,  even  on  an  empty 
stomach,  vomiting  is  frequent,  and  the  ferments  are  absent  when 
the  HCl  secretion  is  lost.  In  nervous  dyspepsia  the  ferments  are 
still  present,  though  HCl  may  be  absent.  When  symptoms  of 
stenosis  have  occurred,  there  can  be  no  difficulty  about  the  diag- 
nosis. The  differentiation  of  nervous  dyspepsia  from  ulcer  be- 
comes difficult  only  in  those  cases  in  which  there  has  been  no 
hematemesis.  The  constant  dependence  of  gastric  pain  upon  the 
food,  the  sharply  circumscribed  pain-points  in  the  epigastric  region 
and  in  the  back,  are  unmistakable  criteria.  We  have  spoken  more 
fully  of  the  differential  diagnosis  in  the  sections  on  the  various 
gastric  diseases  with  which  nervous  dyspepsia  may  be  confounded. 
It  must  not  be  overlooked,  however,  that  nervous  dyspepsia  may 
be  associated  with  some  form  of  organic  gastric  disease. 

Treatment. — The  fundamental  causes  of  disease  should  be 
hunted  up,  and,  if  possible,  removed.  The  prospects  of  doing  this 
are  favorable  if  the  cause  can  be  found  in  the  existence  of  intestinal 
parasites,  floating  kidney,  malaria,  and  certain  remediable  diseases 
of  the  genito-urinary  organs.  In  those  forms  of  nervous  dys- 
pepsia which  depend  upon  an  undue  excitation  of  the  nervous 
system,  due  to  sexual  excesses,  abuse  of  alcohol  and  nicotin,  or 
excessive  mental  and  bodily  exertion,  improvement  can  not  be 
hoped  for  unless  these  states  are  remedied.  Patients  must  be 
impressed  with  the  fact  that  drugs  and  other  treatment  will  not 
improve  them  if  they  persist  in  their  bad  habits.  Particularly 
American  business  men,  who,  with  admirable  energy  but  with  little 
regard  for  their  own  health,  persist  in  executing  work  which  is  too 
severe  for  their  mental  and  physical  constitution,  must  be  taught 
that  the  prime  factor  in  successful  treatment  is  rest,  rest,  rest  !  This 
class  of  cases  will,  in  the  long  run,  prove  to  be  very  grateful  patients 
if  this  truth  is  emphasized,  and  false  expectations  concerning  the 
efficacy  of  drugs,  and  washing  out  the  stomach,  etc.,  corrected  at 
the  beginning  of  the  treatment.  Better  results  can  be  obtained  in  all 
of  these  cases  by  a  change  of  environment,  with  absolute  psychic 
and  physical  quiet,  removal  from  the  cares  and  worries  of  business 
and  household,  than  by  the  most  detailed  and  complicated  treat- 
ment. 

In  connection  with  this  we  must  emphasize  the  value  of  rational 
psychic  treatment  of  nervous  dyspepsia.  The  physician  must,  in  a 
dignified  manner,  attempt  to  merit  the  absolute  confidence  of  his 
50 


766  NERVOUS    DYSPEPSIA. 

patient.  For  this  purpose  we  consider  it  important  that  he  should 
show  a  warm,  sincere  interest  in  the  suffering  of  his  patients,  even 
if,  after  a  repeated  and  thorough  examination,  he  should  become 
convinced  that  the  patient's  complaints  are  unreal  and  exaggerated. 
It  is  a  great  comfort  to  these  neurasthenics  to  listen  patiently  and 
sympathetically  to  their  complaints,  and  not  to  ridicule  or  criticize 
them.  The  sufferings  of  the  patient,  psychically  considered,  are 
equally  intense,  whether  they  be  real  or  imaginative. 

Gymnastics. — The  author  has  frequently  observed  marked  im- 
provement after  a  course  of  mild  gymnastic  training  under  an  experi- 
enced training-master.  The  bicycle,  moderately  used,  is  a  better 
means  of  promoting  appetite  and  regular  evacuations  than  drugs. 
In  a  similar  way,  horseback  riding,  rowing,  fencing,  etc.,  are  to  be 
recommended. 

Climatic  Treatment. — A  sojourn  in  the  mountains  or  at  the  sea- 
shore is  a  great  help,  inasmuch  as  it  not  only  removes  the 
patient  from  surroundings  which  keep  up  his  disease,  but  at  the 
same,  time  insures  rest,  quiet,  and,  above  all  things,  invigorating 
fresh  air.  In  seeking  a  resort,  fashionable  places  and  those 
thronged  with  society  should  be  avoided.  The  greater  part  of  the 
day  should  be  spent  in  the  open  air — if  possible,  in  taking  extensive 
walks.  This  will  favor  good  sleep  during  the  night.  If  there  be 
persistent  hyperagidity  with  constipation,  the  patient  will  be  bene- 
fited by  a  sojourn  at  Bedford  Springs,  Pa. 

Massage. — There  is  no  doubt  that  massage  improves  the  nutri- 
tion of  the  muscles  and  nerves,  and  favors  a  vigorous  circulation, 
metabolism,  and  regular  evacuation.  Massage  should  not  be  per- 
mitted from  inexperienced  quacks.  Nine-tenths  of  the  persons 
claiming  to  be  masseurs  at  the  present  time  are  charlatans.  To  be 
effective,  the  massage  must  be  studied  by  the  physician  who  has  the 
case  in  hand,  and  though  he  can  not  execute  it  himself  he  should, 
at  least,  supervise  it. 

Hydrotherapy. — Cold  sponge  baths,  taken  in  the  morning  immed- 
iately after  arising,  have  a  bracing  effect.  A  good  method  is  to 
wrap  the  entire  body  of  the  patient  in  a  sheet  dipped  in  cold  water, 
and  while  the  patient  himself  kneads  and  beats  the  parts  of  his 
body  that  are  accessible  to  him  in  front,  another  person  must 
perform  the  massage  of  his  back ;  after  this  the  patient  is 
thoroughly  rubbed  with  a  coarse  Turkish  towel.  These  cold  rubs 
should  not  last  longer  than  three  minutes,  after  which  the  patient 


ELECTRICITY    IN    NERVOUS    DYSPEPSIA.  jGj 

must  dress  and  take  a  walk  of  about  one  mile.  The  favorable 
effects  of  hydrotherapeutic  methods  do  not  become  manifest  until 
they  have  been  applied  for  two  to  three  weeks.  They  are  then 
followed  by  improvement  in  the  appetite  and  sleep.  When  the 
insomnia  is  persistent,  we  are  very  fond  of  prescribing  a  warm  salt 
bath,  at  the  temperature  of  the  body,  containing  four  per  cent,  of 
sodium  chlorid  and  two  per  cent,  of  sodium  carbonate.  The 
patient  is  placed  in  this  bath  about  half  an  hour  before  bedtime, 
and  remains  in  it  for  about  twenty  minutes. 

Irrigations  and  Douches  of  the  Gastric  Mucosa. — These  are  used  to 
reduce  the  hyperesthesia  of  the  gastric  nerves,  and  for  this  purpose 
carbonated  waters  are  preferable  to  still  waters.  The  gastric  tube 
should  be  used  which  contains  numerous  small  lateral  openings 
instead  of  a  few  large  terminal  openings.  If  a  carbonated  water 
can  not  be  conveniently  obtained,  it  can  be  prepared  by  adding 
citric  acid  or  lemon  juice  to  a  one  per  cent,  solution  of  sodium  bi- 
carbonate. The  amount  poured  into  the  stomach  should  not  exceed 
20  ounces  at  a  time.     (See  p.  287.) 

Electricity. — Galvanization  of  the  abdomen  and  the  spinal  region 
and  general  faradization  are  applicable  in  these  cases.  The  faradic 
current  should  be  applied  to  every  muscle  in  the  body  with  large, 
broad,  felt  electrodes.  A  good  method  consists  in  placing  the  feet 
of  the  patient  upon  a  large  plate  electrode  (cathode),  while  the 
other  pole  is  placed  on  the  various  muscle  groups  of  the  body.  It 
is  well  to  allow  the  large  electrode  to  remain  on  the  epigastric 
region  for  about  five  minutes,  while  the  remaining  one  is  passed  up 
and  down  over  the  spinal  column.  The  intensity  of  the  current 
and  the  duration  and  localization  of  the  treatment  must  be  varied 
according  to  the  individuality  of  the  case.  According  to  Erb, 
Beard,  and  Rockwell,  this  treatment  improves  the  appetite  and 
sleep,  reduces  the  psychic  irritability,  and  creates  a  more  favor- 
able disposition  to  bodily  exercise.  Personally,  we  may,  without 
defining  the  exact  benefits  derived  from  electric  treatment,  pro- 
nounce it  to  be  an  indispensable  adjunct  to  the  treatment  of  neuras- 
thenia gastrica.  Perhaps  it  influences  the  nutrition  of  the  nervous 
centers,  or  perhaps  it  is  nothing  but  systematic  massage.  At  all 
events,  it  effects  an  improvement  in  the  sufferings  of  this  class  of 
patients. 

The  Diet. — In  this  disease,  more  than  in  any  other,  the  physician 
must  see  that  the  articles  of  food  possess  considerable  variety  and 


^68  NERVOUS    DYSPEPSIA. 

are  well  cooked  and  appetizing.  The  behavior  of  the  digestive 
functions  are  so  grotesque  that  it  is  impossible  and  useless  to 
suggest  stereotyped  diet  lists.  Experience  is  the  best  guide,  and 
the  common  phrase  "  the  proof  of  the  pudding  is  the  eating  of 
it,"  is  certainly  applicable  in  these  cases.  It  is  very  beneficial 
to  the  patient  if  he  can  take  and  well  digest  large  quantities  of 
milk;  aside  from  its  high  nutritive  value,  milk  acts  upon  the 
gastric  mucosa  like  a  soothing  liquid  ointment,  and  is  a  dietetic 
intestinal  antiseptic.  Sometimes  when  the  patient  is  prejudiced 
against  it,  it  is  possible  to  mix  it  with  the  food  surreptitiously,  and 
our  diet  lists  and  "  dietetic  kitchen  "  give  many  formulae  for  foods 
containing  milk.  In  the  selection  of  the  remaining  foods,  the 
taste,  likes,  and  dislikes  of  the  patient  should  be  consulted  so  far 
as  is  consistent  with  rational  dietetics.  Articles  of  luxury,  such 
as  good  fruit,  grapes,  pears,  figs,  dates,  and,  if  anacidity  exists,  fresh 
pineapples,  should  not  be  forbidden.  If  constipation  is  obstinate, 
the  diet  should  contain  a  large  amount  of  these  foods,  and  par- 
ticularly apples.  Concerning  the  use  of  alcoholic  beverages  no 
definite  rule  can  be  given.  On  the  whole,  we  believe  that  wines 
and  beer  should  be  avoided,  unless  they  are  needed  for  stimulation 
and  to  improve  the  appetite.  Large  colon  enemata  with  pure  olive 
oil  (300  c.c.  at  a  time)  are  sometimes  curative  in  the  nervous  consti- 
pation, particularly  the  membranous  colitis  present  in  these  patients. 
Perhaps  the  most  effective  treatment,  on  the  whole,  is  that  desig- 
nated as  the  Weir  Mitchell  rest-cure,  a  combination  of  hydrothera- 
peutic,  electrical,  and  dietetic  treatment,  with  gymnastics,  rest, 
massage,  and  as  much  sleep  as  possible.  Where  the  state  of  the 
nutrition  has  been  much  reduced,  the  so-called  "  Mastkur,"  a  sys- 
tem of  fattening  by  highly  nutritious  diet  and  passive  exercise,  is, 
in  our  experience,  very  effective  in  bringing  about  a  reduction  of 
the  symptoms  and  improvement  in  the  digestive  functions.  This 
"  Mastkur  "  is  not  applicable  to  all  classes  of  patients  ;  those  of  an 
irritable  and  restless  temperament  and  those  who  have  organic 
gastric  diseases  will  become  aggravated  rather  than  improved  by  it. 
Drugs. — Those  that  have  been  employed  in  neurasthenia  gastrica 
are  the  tonics,  sedatives,  and  hypnotics.  In  anacidity,  the  basic 
orexin,  five  grs.  three  times  a  day,  has  been  very  much  lauded  by 
Penzoldt.  The  fluid  extract  of  condurango,  one  teaspoonful  three 
times  a  day,  and  the  bitter  tonics,  calumbo,  gentian,  quassia,  in  doses 
of  one  dram   three  times   a  day,  are  sometimes  of  value,  though 


MEDICINAL    TREATMENT    OF    NERVOUS    DYSPEPSIA.  769 

personally  we  have  seen  no  marked  results  follow  their  administra- 
tion. The  remedy  we  have  most  faith  in  is  the  sulphate  of 
strychnin,  ^q  of  a  grain  three  times  a  day.  When  malaria  is 
associated  with  the  nervous  dyspepsia,  quinin  is  the  remedy  "  par 
excellence."  Boas  and  Einhorn  speak  very  favorably  of  the  use 
of  bromids  ;  both  of  them  employ  mixtures  of  the  ammonium  and 
sodium  bromids.  While  the  remedies  may  have  a  temporary 
value,  and  are  indispensable  for  producing  sleep  and  diminishing 
the  excessive  irritability  of  the  nervous  system,  they  must  not  be 
used  continuously.  We  have  assured  ourselves,  by  quantitative 
analyses  of  the  toxic  products  of  the  urine,  similar  to  the  studies 
of  Herter  and  Smith  {/oc.  cii),  that  the  toxicity  of  the  urine  is 
increased  in  nervous  dyspepsia  as  soon  as  the  total  quantity  of 
bromids  that  is  administered  exceeds  six  gm.  in  twenty-four  hours. 
Maximowitsch  recommends  the  following  in  neurasthenia  gastrica 
on  a  basis  of  anemia  : 

U .      Ferri  bromati, 

Chinin  bihydrobromic, aa 4.0 

Ext.  et  pulv.  rad.  rhei.     q.  s.  u.  f.  pil.  No.  cxx.  M. 

SiG. — D.  S.  two  pills  three  times  daily. 

The  use  of  mineral  spring  waters  is  of  doubtful  efficacy. 
Where  an  improvement  is  noticed  at  the  mineral  springs,  it  is  prob- 
ably due  to  the  hygienic  surroundings,  the  removal  from  care  and 
worry  and  responsibility,  and  the  discontinuance  of  the  detrimental 
habits  encouraged  at  the  home  of  the  patient.  For  further  con- 
sideration of  the  effect  of  mineral  waters  we  refer  to  the  chapter  on 
this  subject  (pp.  300  to  315).  If  the  insomnia  is  persistent,  chloral 
may  be  unavoidable.  It  should,  in  these  cases,  be  given  by  rectal 
enema  and  not  by  the  stomach.  Fifteen  grains  in  two  ounces  of 
starch  water  are  usually  sufficient  to  secure  rest.  An  effective  com- 
bination consists  of  eight  grs.  of  chloral  hydrate  and  eight  grs. 
of  sulphonal.  Opium  and  belladonna  are  best  excluded  from  the 
treatment.  Sulphonal  and  trional  are  available  remedies  for  the 
insomnia,  but,  like  the  chloral,  they  have  a  deleterious  influence 
upon  the  stomach,  and  should  be  preferably  given  per  rectum. 
But  the  treatment  producing  the  most  lasting  results  is  that 
which  tones  up  and  invigorates  the  neuromuscular  apparatus  and 
increases  the  will  power. 


AUTHOR'S   SYNOPSIS   OF   SCHEME    FOR   EXAMINING 

STOMACH    PATIENTS    AT    THE    MARYLAND 

GENERAL    HOSPITAL. 

Medical  No  ...       Name Address Age...       Color 

Sex Social  Condition Diagnosis Date 


HEREDITARY  FACTS  OF  IMPORTANCE. 

PREVIOUS  HISTORY.— Severe  constitutional  diseases?     First  appearance  of  symptoms,  and 

cause?     Did  they  appear  suddenly?    Intensely?    Or  gradually?    Continuous?     Orremittent? 

What  intervals?   Occupation  ?    Habits?   Alcoholism?   Tobacco?   Cold?    Change    of  climate? 

Mental    strain?       Trauma?       Malaria?      Did  it  begin    with    or  without  a  chill?      Fever? 

Yellow  fever?     Constipation?     Diarrhea?    Dysentery?    Typhoid  fever? 
PRESENT   HISTORY. — Diseases  of  other  organs?     Dyspeptic  symptoms?    Pressure?    Local- 

and  subjective  complaints?     Fullness?      Pain?     Distention?     Restlessness?     Sounds  in  the 

digestive  tract?     Bowel  movements?     Nausea?     Eructation?    Vomiting?     Hematemesis? 

Appetite?     Taste?     Thirst? 
LOCAL  SUBJECTIVE  SYMPTOMS.— Any  difficulty  or  pain  on  deglutition?     If  so,  its  regu- 
larity?     Irregularity?      Intensity?      Duration?      Effect  of  food  on  pain ?    Do  they  occur  in 

every  position  of  body  ?     Or  only  in  certain  positions?     Time  of  onset  after  meals?    Pain  at 

night?      On  an  empty  stomach?      Improved  by  eating?      Exaggerated   by  eating?      Is  pain 

diffuse?    Or  circumscribed  ?     Deglutition  sounds? 
ERUCTATION.— Duration  ?    Occurring  on  full  or  empty  stomach?     Is  gas  tasteless?    Odor- 
less?   Acid?     Decomposed?    After  what  foods?     Presence  of  pyrosis,  or  heartburn? 
NAUSEA  AND  VOMITING.— Occurs  on  full  or  empty  stomach?     Frequency?     Taste  of  vomit  ? 

Appearance  of  matter?   Food  particles  ?    Proteids?    Starches?    Mucus?    Bile?    Pus?   Blood? 

Food  eaten  several  days  before?     Does  emesis  relieve  symptoms? 
APPETITE  AND  THIRST.— Accustomed  diet  (let  the  patient  state  in  detail  what  is  eaten  during 

the  entire  day)?    Mode  of  life?    Anorexia?     Bulimia?    Aversion  to  meat?    Thirst? 
BOWELS.— Constipation?    Diarrhea?      Undigested  particles  of  food?     Mucus?      Pus?     Blood 

and  source? 
RESULTS  OF  BLOOD  EXAMINATION. 
GENERAL  NUTRITION.— Emaciation  ?     Loss  of  weight  in  pounds?    In  what  time? 

PHYSICAL  EXAMINATION. 
INSPECTION.— Change  in  form  of  abdomen?     Tumor?    Gastric  or  intestinal  peristalsis  ? 
PALPATION. — Time  of  examination  ?     Temperature?     Outline   of  stomach?    Upper  border? 

Lower  border?     Presence   of  tumor?     Movement   of  tumor?    Was   stomach  full  or  empty? 

Pain  on  pressure?     Diffuse  or  circumscribed?    Succussion  sound  ? 
PERCUSSION.— Limits  of  the  stomach? 
DISTENTION  WITH  AIR  OR  GAS.— Limits  of  stomach?    Results  with  intragastric  bag?    Does 

tumor  move  with  distention?     Made  more  or  less  distinct? 
ELECTRODIAPHANY.— Limits  of  stomach?     Tumor? 

EXAMINATION  OF  TEST-MEALS. 
Double  test-meal  of  the  Maryland  General  Hospital  (see  p.  iii)  at  say  9  A.  M. 

Ewald  test-meal  at  say  2  p.  M.  Contents  drawn  at  say  3  P.  M.  Date 

MICROSCOPICAL  EXAMINATION. -Quantity?      Color?     Odor?     Food  particles  ?     Froth  or 

gas?     Pus?     Mucus?     Bile?    Blood?    Fragments  of  tissue?    Bacteria?    Oppler-Boas  bacilli? 

Sarcinse? 
CHEMICAL  EXAMINATION.— Reaction  ?     Free  acid?     FreeHCl?     Lactic  acid  ?     Amount 

freeHCl?    Combined  HCl?    Amount  acid  salts  and  organic  acids?    Total  acidity  ?    Erythro- 

dextrin?     Deficit  of  HCl? 

PEPSIN. 

Albumin  digested  in  pure  filtrate  in. ..  .minutes.     Albumin  digested  in  acidified  filtrate  in.... 
minutes.    Albumin  digested  in  HCl  and  pepsin  filtrate  in.. .  .minutes. 

RENNET. 

Milk   coagulated  by  rennin  in.... minutes.     Milk  coagulated  by  rennin-zymogen  in minutes. 

Rennin-zymogen  active  in  dilution  i. 
CONTENTS. — After   meal  previous  evening  at  8  p.  M. 
CONTENTS. — After  lavage  previous  evening  at  8   p.  m. 
TIME  OF  SALOL  REACTION  ...minutes. 

TIME  OF  lODID  OF  POTASSIUM  RESORPTION  TEST...  .minutes. 
URINE. — Amount?     Urea?      Reaction?      Indican?      Preformed  sulphates?     Albumin?      Tube 

casts?    Ethereal  sulphates?     Ratio?    Sugar?    Specific  gravity  ? 

TREATMENT. 

Diet?     Medicines?     Electricity?     Massage?     Hydrotherapy?    Lavage?    Mineral  spring  water? 
Gymnastics?    Orthopedic  treatment?     Results? 

770 


LIST  OF  AUTHORS, 


The  List  of  Authors  and  Table  of  Contents  were  compiled  by  Mr.  James  W.  Kissling 
[Candid.  Med.).  The  author  herewith  expresses  his  thanks  for  the  intelHgent  way  in 
which  this  work  has  been  executed. 


Abelous,  bacteria  in  the  stomach,  64 
Adler,    diseases    of    the    heart     and    the 

stomach,  372 
Albu,  auto-intoxication,  359,  692;   gastric 

tetany,   362 ;    coma    carcinomatosum, 

524 

Alt,  merycism,  665 

Ames,  phlegmonous  gastritis,  410 

Anderson,    nutritive    enemata,     197 ;     ab- 
stinence cure  for  ulcer,  484 

Arnold,  cancer,  529 

Atkinson,  digestibility  of  foods,  215 

Atwater,  dietaries,  212 


Bachmeier,  floating  kidney,  625 
Baginsky,  pepsin  and    trypsin  interaction, 

Bamberger,  gastromalacia,  464 

Bardet,  electric  therapy,  290 

Barie,  asthma  dyspepticum,  366 

Bartels,  gastric  inflammatory  atrophy,  426 

Baruch,    Dr.    Simon,  hydrotherapy,    296 ; 

natural  mineral    waters — comparative 

charts,  300,  et  seq. 
Bauer,  rectal  alimentation,  201 
Beard,  electric  therapy,  290 
Beaumont,    peristalsis,   84,    85  ;     stomach 

surgery,  336 
Beck,  cancer,  506 
Bensley,  histology  and  physiology  of  the 

gastric  glands,  25 
Bernabes,  myoma,  567 
Bernard,  Claude,  pancreatic  juice,  57,  67; 

self-digestion  of  the  stomach,  463 
Berthelot,  steapsin.  58 
Best,  foreign  bodies  in  the  stomach,  570 
Beynard,  electric  stimulation,  289 
Biedert,  achylia,  745 
Biernacki,  kidney  diseases  and  the  stomach, 

373 


Bikfalvi,  alcohol  in  digestion,  278 
Billroth,  surgery,  337,  338,  347 
Bircher,  Dr.  Heinrich,  gastrorrhaphy,  598 
Blake,  Dr.  John  D.,  gastralgia  and  adhe- 
sions, 695 
Blank,  digestion  of  fats,  62 
Boas,  peptic  gland  cells,  23  ;  ptyalin  diges- 
tion, 46  ;  duodenal  chyme,   67  ;  test- 
meal,  III  ;  bile  and  duodenal  secre- 
tions in  stomach  contents,  121  ;   epi- 
thelial   exfoliations,    126,   129;   lactic, 
acid  test-meal,  152,  153  ;   analysis  for 
HCl — method,   157  ;   lactic  acid  esti- 
mation, 160;  pepsin  and  pepsinogen 
tests,    166  ;  rennin  and  rennin-zymo- 
gen   estimation,    166;  dietetics,    184, 
185;     nutritive    enemata,     197;    diet 
lists,  223,  237,  238;   massage,    296; 
alkali  therapy,  325,  328  ;    gastric  sur- 
gery and  secretion.  344  ;   asthma  dys- 
pepticum,   366 ;     infectious    gastritis, 
413  ;   gastritis  acida,  434  ;  ulcus  car- 
cinomatosum,   525  ;    gastralgia,   693  ; 
gastric  crises,    728;    achylia  gastrica, 

747        .  . 
I^occi,  electricity,  peristalsis,  and  secretion, 

289 
Bollinger,  glanders  in    the   stomach,  549  ; 

foreign  bodies,  571 
Booker,  W.  D.,  pathologic  gastric  mucosa, 

135  ;   acute  gastritis,  398 
Borutteau,  secretion  and  peristalsis,  89 
Bottcher,  infectious  gastritis,  416;  gastric 

ulcer,  466 
Bouchard,  gastric  diseases  and  respiration, 

360 
Bouveret,  artificial  stomach  distention,  98  ; 

gastric  diseases  and  respiration,  360 ; 

gastric    secretion,    139  ;     alcohol  and 

tetany,  184;   tetany  and  lavage,  286, 

362  ;    acute    gastritis,    397 ;    gastritis 

atrophicans,  436  ;  nervous  eructation, 

651  ;    bulimia,    704;     gastric     crises, 

728 


771 


772 


LIST    OF    AUTHORS. 


Brabazon,    gastric    inflammatory    atrophy, 

426 
Brandl,  gastric  absorption.  91,  92 
Braun,  organic  acids — analysis,  162 
Brenner,  gastro-enterostomy,  338 
Brinton,  gastric  glands,  26  ;   peristalsis,  86 
Broadbent,  Sir  William  H.,  anorexia,  183  ; 

pyloric    stenosis,   453  ;    motor  insuffi- 
ciency, 735 
Brock,    galvanism    and    gastric    neuroses, 

294 
Brooks,  valvulre  conniventes,  34 
Brown-Sequard,    the    stomach    in  nervous 

diseases,  368  ;   gastromalacia,  464 
Briicke,  pepsin  determination,  166 
Brunner,  peristalsis  testing,  72 
Bryant,  Jos.  D.,  cancer — statistics,  510 
Bunge,  HCl  an  antiseptic,  64 
Burkhart,    dietetics,    19S,    199,  240,241; 

neurasthenia  gastrica,  761 
Burton,  pancreatic  juice,  58 
Busch,    digestion    in    the  absence   of    the 

usual  ferments,  206 


Cabot,  Richard  C. ,  examination  of  gastric 

contents  for  blood,  124 
Cahn.  fatty  acid  determination,  161  ;  pre- 

digested  food,  200 
Canstatt,  electric  therapy,  290 
Capelle,    foreign   biidies   in    the    stomach, 

571 
Captain,  gastric  bacteria,  64 
Cartellieri,  eructations,  651 
Charcot,  gastric  crises,  632 
Chittenden,    Prof.    R.    H.,    saliva,      163; 
composition    of    beef  products,    191  ; 
alcohol  in  digestion,  275 
Chomel,  diet  in  dilatation,  193 
Chomele,  dilatation,  585 
Christomanos,  antiperistalsis,  204 
Church,  food  energy,  218 
Chvostek,  purulent  gastritis,  412 
Cohnheim,  ulcer,  464-466  ;  cancer,  506 
Cohnheim,    Paul,  mucosa   fragments,  8^  ; 

achylia  gastrica,  746 
Connor,  Dr.,  gastric  surgery,  337 
Contejean,  peristalsis  and  secretion,  89 
Cornil,   diagnosis  of  cancer,  529  ;  lymph- 
adenoma,  549  ;  polypi,  566 
Courvoisier,  gastro-enterostomy,  337 
Cruveilhier,  polypi,  566 
Cseri,  massage,  296 

Czerny,   resection,  337;   pyloroplasty  and 
resection,  349 


D. 

Daettwyler,  gastric  ulcer,  466 
Dauber,  antiperistalsis,  204 


Debove,  secretion    of   the   stomach,    139 
tetany  from  lavage,  286,  362 

Decker,  gastromalacia,  465 

Deininger,  gastric  abscess,  412 

Deiters,  predigested  foods,  199 

Delafield,  acute  gastritis,  398 

Devic,  gastric  fermentation  and  tetany,  184 

Dobson,  Nelson  C,  ulcer,  485 

Dock,  George,  cancer,  527 

Donders,  dietetics,  177 

Donkin,    H.    B.,  nutritive  enemata,    197  ; 
abstinence  cure  for  ulcer,  484 

Dreyer,  George  R..  electric  stimulation,  83 

Dubey,  hypertrophic  sclerosis,  421 

Duchenne,  electrotherapy,  290 

Dujardin-Beaumetz,  carbohydrates   in    hy- 
peracidity, 188;   dietaries,  212 


Earl,  Dr.  Samuel  T.,  tuberculous  rectal 
fistula,  371 

Eberth,  carcinoma,  528 

Ebstein,  nervous  diseases  and  the  stomach, 
368  ;   gastromalacia,  464  ;  polypi,  566 

Edinger,  L.,  acute  gastritis,  397 

Edkins,  acid  and  formation  of  pepsin,  28 

Eichhorn,  subcutaneous  feeding,  210 

Eichhorst,  peristalsis  testing,  72  ;  spectro- 
scopic examination  for  blood,  124; 
rectal  alimentation,  201  ;  acute  gas- 
tritis, 403 

Einhorn,  Dr.  Max,  gastrograph,  75  ;  mu- 
cosa exfoliations,  83  ;  gastrodiaphany, 
102;  stomach  bucket,  no;  erosions 
of  the  stomach,  126,  129;  their  patho- 
logical significance,  131  ;  gastric  se- 
cietion  in  the  fasting  state,  139,  140  ; 
intragastric  spray,  287  ;  electric  stim- 
ulation, 289,  291,  292  ;  intragastric 
electrode,  290 ;  digestive  ferments  as 
medicinal  agents,  329  ;  electricity  in 
chronic  gastritis,  448 ;  trauma  and 
ulcer,  468  ;  gastrosuccorrhea,  736  ; 
achylia  gastrica,  743,  747,  749 

Eiselsberg,  von,  pylorectomy,  345  ;  phyto- 
bezoar, 572 

Elsasser,  gastromalacia,  464 

Emmerich,  bile  action,  61 

Engel-Reimers,   cysts,  569 

Escherich,  bacteria  in  digestion,  63,  71 

Ewald,  ferment  action,  48,  67,  68  ;  peri- 
stalsis, 72;  test-meal.  III,  II2  ;  mu- 
cosa exfoliations,  125,  129  ;  secretions 
from  the  fasting  stomach,  139,  140  ; 
nutritive  enemata,  202  ;  diet  list,  223  ; 
massage,  296 ;  saline  vraters,  302 ; 
formula  for  anorexia,  328;  tetany, 
364  ;  nervous  diseases  and  the  stom- 
ach, 368;  abscess,  412;  gastromala- 
cia, 465  ;  syphilitic  ulcer,  559  ;  foreign 
bodies  in  stomach,  569  ;   bulimia,  701 


LIST    OF    AUTHORS. 


773 


Faber,  absorption,  gi 

Fenwick,  Samuel,  insufficiency  of  secre- 
tion, 317  ;  gastric  inflammatory  atro- 
phy, 426  ;   atrophy  and  anemia,  746 

Fenwick,  W.  Soltau,  poisoning  by  lavage, 
286 ;  pulmonary  diseases  and  the 
stomach,  369 

Fermaud,  gastritis  parasitaria,  416 

Flechsig,  mineral  springs,  300,  et  seq. 

Fleiner,  electrodiaphany,  103  ;  test-meals, 
III,  112;  alcohol  and  tetmy,  1S4; 
carbohydrates  in  hyperacidity,  188  ; 
sarcomata,   512 

Fleischer,  peristalsis,  74  ;  gastrodiaphany, 
102  ;  diet  list,  237,  23S;  HCl  com- 
bining power  of  foods,  239 

Flexner.  Dr.  S. ,  tubercular  ulcer,  551 

Fliess,  gastric  neuroses,  198 

Flint,  Austin,  HCl  as  medicinal  agent, 
317;  gastric  inflammatory  atrophy, 
426 :  anemia  and  atrophy,  747 

Foote,  E.  M.,  ulcer,  485 

Foster,  gastromalacia,  464 

Fowler,  intravascular  feeding,  209 

Fox,  Wilson,  ulcer  cure,  483 

Frankel,  A.,  asthma  dyspepticum,  367 

Frankel,  C. ,  acute  gastritis,  402 

Frerichs,  gastric  glands,  26 

Freund,  bimanual  palpation  of  the  kidney, 
617 

Friedenwald,  Dr.  Julius,  acidities  after 
test-meals,  II2;  toxic  products  in 
gastric  diseases,  358 

Fubini,  electricity,  peristalsis,  290 


G. 

Gafifky,  infectious  gastritis,  414 
Galeotti,  diagnosis  of  cancer,  529 
Gerhardt,  C. ,  eroded  mucosa,  125  ;   ulcer, 

198;  gastritis  parasitaria,  416 
Gersunny,  dietetics  in  stenosis,  195 
Gessner,  bacteria  as  ferments,  62 
Glax,  purulent  gastritis,  410 
Glenard,  Glenard's  disease,  613 
Gluczinski,  test-meal,  ill 
Gmelin,  tryptophan,  59;   bile  test,  121 
Goldschmidt,    electricity,    peristalsis,  and 

secretion,   291 
Golgi,  mucosa  histology,  24 
Gombauldt,  hypertrophic  sclerosis,  421 
Graaf,  Regnier  de,  intestinal   contents,  54 
Griitzner,  rectal  alimentation,  202,  203 
Gussenbauer,  gastr.c  surgery,  336 


H. 

Haberkant,  Dr. ,  gastric  surgery,  336  ; 
statistics  on  surgical  operations,  340— 
357 


Habershon,  statistics  on  gastric  ulcer,  471 

Hacker,  von,  gastro-enterostomy,  338, 
339)  345>  347;  gastro-anastomosis, 
354  ;  surgery  for  ulcer,  486 ;  NaCl 
infusion  for  gastric  hemorrhage,  486  ; 
hour-glass  stomach.  592 

Hahn,  surgical   treatment,  344,  348 

Halliburton,  W.  G. ,  pancreatic  juice,  58 

Halliday,  Andrew,  merycism,  664  ' 

Hamilton,  Dr.  Alice,  tuberculous  ulcers, 
552 

Hammarsten,  rennin  zymogen  test,  53  '■> 
composiiion  of  bile,  60  ;  bile  action, 
66 

Hanot,  hypertrophic  sclerosis,  421 

Hansemann,  mitosis  in  diagnosis  of  cancer, 
528  ;   tumors,  571 

Hartung,  mucosa  fragments,  125 

Hauser,  cancer,  506  ;  ulcus  carcinomato- 
sum,  525 

Hayem,  mucosa  pathology,  129  ;  anemia, 
chlorosis,  and  gastric  diseases,  369  ; 
achylia  gastrica,  749 

Hehner-Seeman,  organic  acid  estimation, 
162 

Heidenhain,  peptic  gland  cells  and  their 
secretions,  23,  24,  27,  50 ;  function 
of  bile,  61 

Heinecke,  von,  pyloroplasty,  348  ;  puru- 
lent gastritis,  413 

Heinsheimer,  metabolism  in  gastro-enter- 
ostomy, 353 

Hemmeter,  Dr.  John  C.,  duodenal  intuba- 
tion, 54  ;  intestinal  putrefaction,  65  ; 
peristalsis,  76-90 ;  intragastric  stom- 
ach-shaped rubber  bag,  77,  80—83, 
89  ;  test  for  absorption,  93-96  ;  en- 
terodiaphany,  103  ;  double-current 
stomach-tube,  105,  et  seq.  ;  signifi- 
cance of  mucosa  exfoliations.  131- 
135;  digestibility  of  foods,  179;  di- 
gestion of  enemata,  204 ;  dietaries, 
223,227;  alcohol  and  gastric  motil- 
ity, 279  ;  formula  for  anorexia,  327 ; 
gastric  tetany,  364;  kidney  diseases 
and  the  stomach,  373  ;  phlegmonous 
gastritis,  410  ;  electricity  and  chronic 
gastritis,  448  ;  gastromalacia,  463  ; 
gastric  ulcer  treatment,  482 ;  ulcus 
carcinomatosum,  525  ;  Roentgen-ray 
photography  of  the  stomach,  589  ; 
merycism,  665;  schema  for  examining 
stomach  patients,  770 

Hemmeter.  Mrs.  Dr.  J-  C.,  dietetics,  273 

Henne,  HCl  therapy,  319 

Henoch,  asthma  dyspepticum,  364 ;  the 
tongue  in  chronic  g.istritis,  432 

Henry,  gastric  atrophy  and  anemia,  747 

Hensen,  Hans,  bacterial  invasion  of  the 
digestive  tract,  65 

Herschel.  absorption,  91 

Herter,  nervous  dyspepsia,  762 


774 


LIST    OF   AUTHORS. 


Hildebrandt,  gastritis  parasitaria,  416 

Hippocrates,  dietetics,  177 

Hirschler,  carbohydraies  and  putrefaction, 

69 
Hodder,  intravascular  feeding,  209 
Hodge,  C.  F.,  effect  of  electricity  on  nerve 

elements.  289 
Hoffmann,  secretion  in  the  jejune  stomach, 

138,    140;    electricity    and    secretion, 

289;  gastritis,  423 
Hofmeister,  peristalsis,  84 
Honigmann,  dietetics,  185  ;    HCl  therapv, 

318 
Hoppe-Seyler,    effect     of     exanthematous 

diseases  on  the  gastric  mucosa,  390 
Horner,  gastralgia  and  lipoma,  694 
Howell,  W.   H.,  amylolysis,  47  ;  peristal- 
sis, 84 
Huber,  peristalsis    test,  73  ;   gastric  secre- 
tion,   139,    140;    rectal   alimentation, 
202 
Hiifler,  gastrodiaphany.  102 
Hunter,  autodigestion  of  the  stomach,  463 
Husemann,  infectious  gastritis,  414 
Hutchinson,  pulmonary  diseases   and    the 
stomach,  370 

J- 

Jacobsohn,  prolapsus  and  dilatation,  676 
Jaksch,  von,  rectal  contents,  69  ;   detection 
of  lilood,  124  ;   carbohydrates  and  hy- 
peracidity,   188;     on     the    diazo    re- 
action,   403  ;    coma    carcinomatosum, 

524 

Jaworski,  rennin  test,  53  ;  colon  contents, 
68  ;  test-meal,  ill  ;  secretion  stimu- 
lation, 140  ;  secretion  and  peristalsis 
after  gastric  operations,  344  ;  achylia 
gastrica,  746 

Jenner,  bimanual  palpation  of  the  kidney, 
.      617 

Johnson,  Dr.   R.  W. ,  gastric  surgery,  735 

Johnson,  Wyatt,  acute  gastritis,  402 

Jones,  Allen  A.,  gastric  secretion,  140; 
electrotherapy,  294  ;  renal  diseases 
and  the  stomach,  374;   anacidity,  747 

Jones,  Bruce,  urinary  changes  in  stomach 
diseases,  382 

Jiirgens,  nervous  dyspepsia,  759 


K. 

Kaiser,  surgery,  336.  533 

Kansche,  surgical  treatment,  secretion,  and 
peristalsis,  344 

Karst,  subcutaneous  feeding,  210 

Kaufmann,  Oppler-Boas  bacillus,  120 

Kazzander,  valvule   conniventes,  34 

Key,  Axel,  ulcer,  466 

Kinnicutt,  F.  P.,  gastric  atrophy  and  ane- 
mia, 317)    747 


Klebs,  ulcer,  465  ;  cancer,  506  ;  infectious 

granulomata,  552 
Kleinwachter,  acute  gastritis,  405 
Klemperer,  peristalsis,  73;  test-meal,  III  ; 

acute  gastritis,  397 
Klikowicz,  alcohol  in  digestion,  278 
Koch,  nervous  diseases  affecting  the  stom- 
ach, 368  ;  gastromalacia,  465 
KoUiker,  gastric  glands,  26 
Kooyker,   foreign  bodies  in  the  stomach, 

'570 
Kramer,  stomach  operations,  343 
Krompecher,  cancer— diagnosis,  528 
Krueg,  subcutaneous  feeding,  210 
Kuhn,  F.,  HCl  action  on  yeast,  141  ;  pre- 
digested    foods,   200 ;  pyloric    sound- 
ing. 590 
Kiihne,  trypsin  and  pepsin  interaction,  67 
Kundrat,    infectious  gastritis,  415  ;   sarco- 
mata ;  512,  et  set]. 
Kupffer,  border  cells  in  fundus,  23 
Kussmaul,   alcohol — tetany,    184  ;   diet  in 
dilatation,  193;  gastric  douche,  286; 
electric  therapy,  290;  gastric  tetany, 
362 
Kuttner,  differentiation  between  prolapsus 
and  dilatation  of  the  stomach,  676 


Lambl,  polypi,  566 
Landau,  splanchnoptosis,  614 
Landenberger,  hypodermic  feeding,  210 
Langley,  ferment  and  acid  cells,  28  ;  pep- 
sin and  trypsin  interaction,  67 
Larrey,  stomach  surgery,  336 
Lauenstein,  gastro-enterostomy,  337 
Lauterbach,  asthma  dyspepticum,  365 
Legroux,    transfusion    for    hemorrhage    in 

ulcer,  486 
Lemoine,  alkali  therapeutics,  322 
Leo,  secretion  in  the  fasting  stomach,  138  ; 
estimation  of  HCl,  159  ;  bulimia,  701 
Lerov,     transfusion — hemorrhagic      ulcer, 

486 
Letulle,   ulcer,  466 

Leube,  peristalsis,  72;  test-meal.  III; 
gastric  secretion  test,  140 ;  nutritive 
enema,  202  ;  subcutaneous  feeding, 
210  ;  dietaries,  232  ;  alkali  therapy, 
322 ;  gastric  and  intestinal  vertigo, 
361  ;  acute  gastritis,  403  ;  gastric  ab- 
scess, 412  ;  gastromalacia,  464  ;  ulcer 
cure,  483  ;  nervous  dyspepsia,  758 
Leven,  nervous  dyspepsia,  761 
Lewin,  bacterial   invasion  of  the  walls  of 

the  digestive  tract,  65 
Leyden,  dietetics,  195  ;  juvenile  vomiting, 

656 
Linossier,  therapeutics  of  alkalies,  322 
Lobker,    pyloroplasty    and     pylorectomy, 
349,  350 


LIST    OF    AUTHORS. 


775 


London,  ulcer,  465 

Loreta,  digital  divulsion  of  pylorus,  349 

Loye,  electric  stimulation,  289 

Lubarsch,  O.,  insufficiency  of  gastric  se- 
cretion, 317  ;  achylia  gastrica,  743 

Lucksdorf,  bacteria  of  mouth  and  intes- 
tine, 64 

Ludwig,  electricity  and  the  motor  func- 
tion, 290;  mineral  springs,  300,  et 
seq. 

Liittke,  HCl  determination,  157 


M. 

Macfadyen,  bacteria  in  economy  of  diges- 
tion, 63  ;  ileum  contents,  68 

Macleod,  abscess,  41 1 

Magendie,  vomiting,  653 

Maisoneuve,  surgery,  337 

Malbranc,  gastric  douche,  286 

Mall.  F.,  anatomy  of  the  stomach,  17  ;  pep- 
tic glands,  cells,  and  their  secretions, 
24-28,  90;   antiperistalsis,  207 

Maly,  HCl  formation,  50 ;  bile  and  putre- 
faction, 61 

Mannaberg,  sustenance  of  colon  bacteria, 

Marfan,    stomach    in  pulmonary  diseases, 

369 

Martin,  interaction  of  secretions,  67  ;  gas- 
tric absorption,  92;  detection  of  sar- 
cinse,  119;  anthrax  gastritis,  415; 
ulceration,  468 

Martins,  secretions  in  the  fasting  stomach, 
13^'  '39;  HCl  determination,  157; 
insufficiency  of  secretion,  317,  743 

Mathieu,  total  quantity  of  gastric  contents, 
140  ;  acidity  of  the  urine  and  gastric 
contents,  713 

Mayer,  gastric  vertigo,  361  ;  autodigestion, 

464  ... 

McCall,  treatment  of  ulcer  by  nutritive 
enemata,  197 

Mehring,  von,  starch  digestion,  48;  gas- 
tric absorption,  66,  92,  94,  183  ;  analy- 
sis for  fatty  acids,  161  ;  subphrenic 
abscess,  482 

Meinert,  acute  gastritis,  405 

Meltzer,  S.  J.,  electric  stimulation,  80,  291- 
293 ;  electricity  in  chronic  gastrins, 
448 

Menche,  bitter  tonic  treatment,  328 

Mendel,  alcohol  and  digestion,  275 

Menzel,  hypodermic  feeding,  209 

Merrem,  stomach  surgery,  336 

Meschede,  gastritis  parasitaria,  416 

Mesnil,  du,  alkali  therapy,  322 

Metschnikoff,   interaction  among  bacteria, 

63 
Meyer,  G.,  HCl  in  gastric  therapy,  317 
Michaelis,  gastric  hemorrhage,  486 
Michel,  gastric  hemorrhage,  486 


Mikulicz,  gastroscopy,  170;  statistics  in 
gastrectomy  and  gastrotomy,  339, 
340 ;   pyloroplasty,  348 

Miller,    mouth   microbes,  64 ;    absorption, 

93.  94 
Milliot,  transillumination,  102 
Minassian,  H.  A.,  merycism,  664 
Minkowski,  bacteria  in  the  stomach,  120; 

dietetics,  193 
Mintz,  HCl  as  remedial  agent,  318;  py- 

lorectomy,  345 
Mitchell,  Weir,  fattening  rest-cure,  198 
Miura,  alcohol  as  a  food,  275 
Morau,  HCl  in  gastric  antisepsis,  64 
Moritz,  stomach  support,  19;   intragastric 
apparatus,  77,  83  ;   circulation  of  gas- 
tric ingesta,  89 
Morris,  Henry,  gastrotomy,  338 
Moss,  analysis  of  a  man,  21 1  ;   percentage 

nutrition  of  foods,  215 
Miiller,  intestinal  auto-intoxication,  359 
Munk,   J.,  bile   and   absorption,   61  ;  pre- 
paration of  food,  185 
Murphy,  surgery,  352 
Murray,  lipoma,  567 


N. 

Naunyn,  abnormal  retention  of  ingesta, 
192 

Nencki.  bile — agency  in  pancreatic  diges- 
tion, 61  ;  fat  decomposition,  62  ; 
bacteria  in  digestion,  63  ;  ileum  con- 
tents, 68 

Neubauer,  absorption  test,  95 

Neumeister,  schemata  of  digestion — amy- 
lolytic,  48;  proteolytic,  51,  59; 
biliary  diastatic  ferment,  60 

Noorden,  von,  deficiency  of  gastric  juice 
and  health,  317  ;  HCl  therapy,  318  ; 
malnutrition,  358  ;   gastric  crises,  728 

Nothnagel,  antiperistalsis,  203,  204  ;  in- 
sufficient secretion,  317;  gastric  in- 
flammatory atrophy,  426 

Novarro,  gastro-enterostomy,  351 

Nuttal,  bacteria  not  essential  to  digestion, 
63 

O. 

Obalinski,  secretory  and  motor  functions 
as  affected  by  surgical  operations,  344 

Ogata,  albumin  as  food,  200 

Oppel,  anatomy  of  the  stomach,  17  ;  achy- 
lia gastrica,  752 

Oppler,  sarcinse,  119;  asthma  dyspepti- 
cum,  365  ;   achylia,  750 

Oppolzer,  gastromalacia,  464 

Orth,  acute  gastritis,  397  ;  infectious  gas- 
tritis, 415  ;  gastritis  polyposa,  421  ; 
carcinoma,  492,  et  seq.  ;  infectious 
granulomata,  549 


77^ 


LIST    OF    AUTHORS. 


Oser,  infectious  gastritis,  413  ;  fai^adic 
current  in  gastralgia,  699 

Osier,  gastric  atrophy  and  pernicious  ane- 
mia, 317,  747  ;  carcinoma,  352  ;  acute 
gastritis,  391,  403  ;  chronic  gastritis, 
426;  abdominal  tumors,  519,  52I) 
523  ;  tubercular  ulcer,  551  ;  dilatation, 
584;   splanchnoptosis,  618 

Ott,  infusion  treatment  for  ulcer,  486 


Panecki,  gastralgia  and  the  uterus,  694 

Panuni,  gastromalacia.  464 

Park,  Roswell,  cancer,  50S 

Pasteur,  bacteria  in  digestion,  62 

Pavy,  self-digestion,  463 

Pean,  resection,  337 

Pedioux,  cutaneous  diseases  and  the 
stomach,  374 

Penzoldt,  absorption,  91 ;  stomach-tube, 
107;  dietetics,  185,  194;  dietaries, 
219-222,  226,  232  ;  bitter  tonics,  326  ; 
dilatation,  579  ;   hunger,  708 

Pepper,  electricity — peristalsis,  290  ;  dila- 
tation, 585 

Perco,  hypodermic  feeding,  209 

Pettenkofer,  bile — acid  demonstration,  122 

Peyer,  bulimia,  703  ;  gastralgia  and  genito- 
urinary diseases,  694 

Pick,  secretions  in  the  empty  stomach, 
138 

Pitt,  lymphadenoma,  568 

Playfair,  fattening  rest-cure,  198 

Podwyssozki,  pepsin  production,  27 

Posner,  bacterial    invasion  of  bowel  wall, 

Potain,  asthma  dyspepticum,  366 
Pribram,  gastric  vertigo,  361 
Prudden,  acute  gastritis,  398 


Quinke,  chronic  gastritis,  426  ;   ulcer, 


R. 

Ranke,  bile,  60 

Ranvier,  lymphadenoma,  549 

Rauber,  villi,  34 

Reaumur,  stomach  contents,  54 

Reiche,  hour-glass  stomach  and  ulcer,  481 

Reichert,  alcohol  as  a  food,  275 

Reichmann,    gastric    secretion,   139  ;   HCl 

as    a    medicinal    agent,    318 ;     alkali 

therapy,  323  ;   bitter  tonics,  327  ;  gas- 

trosuccorrhea,  728,  731 
Rem  )nd,    stomach    secretion,    139,    140; 

hour-glass  stomach,  591 
Remsen,  Ira,  mineral  spring  water,  446 


Richards,  Mrs.  E.  H.,  rations,  216 

Richet.  acid  and  pepsin,  28 

Rieder,  cancer,   527 

Riegel,  peristalsis  test,  72  ;  determination 
of  location,  size,  and  capacity  of  the 
stomach — methods,  98,  loi,  103; 
test-meal.  III  ;  sarcinse,  119  ;  Oppler- 
Boas  bacillus,  120 ;  secretions  in 
fasting  stomach,  138 ;  nutritive  ene- 
mata,  197,  203  ;  predigested  foods, 
200  ;  gastric  douche,  287  ;  massage, 
296  ;  hyperacidity  and  ulcer,  467  ; 
HCl  in  therapeutics,  318  ;  bitter  ton- 
ics, 327  ;  asthma  dyspepticum,  365  ; 
hypersecretion,  733 

Rindfleisch,  ulcer,  466 

Ritter,  gastromalacia,  465 

Roberts,  vSir  William,  effects  of  cooking 
on  food,  242 ;  "  indications  of  the 
palate,"  243  ;  alcohol  in  diges- 
tion, 278,  2S1,  282;  hyperacidity,  712 

Rockwell,  electrotherapy,  290 

Rohmann,  bile  and  intestinal  peristalsis, 
61 

Rokitansky,  gastromalacia,  464 

Rollet,  gastric  gland  cells,  23,  26 

Rondeau,  myoma,  567 

Rosenbach,  asthma  dyspepticum,  365 

Rosenheim,  gastric  cells,  23 ;  stomach- 
tube,  108  ;  gastroscopy,  170,  173, 
176  ;  pancreatic  ferment,  206  ;  gastric 
douche,  287  ;  massage,  296 ;  secre- 
tion and  the  motor  function,  following 
surgical  operations,  344  ;  chronic  gas- 
tritis, 426  ;  carcinomatous  ulcer,  481, 
525;  carcinoma  diet,  540 ;  gastralgia 
and  median  hern're,  694 

Rosenstein,  stomach   in  diabetes  mellitus, 

373 
Rosenthal,  hydrotherapy,  295  ;  gastroxyn- 

sis,  727 
Rosin,  secretion  in  the  jejune  stomach,  138 
Rossbach,  gastroxynsis,  727 
Rossi,  electric  stimulation  to  secretion,  289 
Rotch.  acute  gastritis,  397 
Roux,  W. .  proteids   an!    carbohydrates  in 

hyperchlorhydria,  188 
Rummo.    carbohydrates  v^.  proteids  in  the 

treatment  of  hyperacidity,  188 
Runeberg,  artificial  stomach  distention,  98 
Rupp,  resection,  347 
Ruysch,  cysts,  569 
Rydygier,  resection,  337 


S. 

Sachs,  achylia  gastrica,  752 
Salkowsky,  absorption  test,  95 
.Salzer,  Henry,  test-meal,  ill,  114 
Scammell,  relative  value  of  foods,  214 
Schech,  the  mouth  in  gastritis,  432 
Scheperlen,  chronic  gastritis,  426 


LIST    OF   AUTHORS. 


71-7 


Schetty,  acute  gastritis,  397 

Schiff.  pepsin  and  acid,  28;  gastric  ulcer, 
464;  stomach  in  nervous  diseases. 
368 

Schillbach,  electricity  and  peristalsis, 
289 

Sclilesinger,  Oppler-Boas  bacillus,  120 ; 
sarcoma,  511 

Schmidt,  Adolph,  mucosa  in  gastric. dis- 
eases, 135 

Schmidt,  F.,  gastric  fever,  402 

Schonborn,  foreign  bodies  in  the  stomach, 

Schreiber,  J.,  secretions  in  fasting  stom- 
ach, 138,    139,    731,   733 ;   dilatation, 

434 

Schuchardt,  pylorectomy,  346 

Schiitz,  peristalsis,  84 

Schwartz,  infusion  of  salt  solution  in  hem- 
orrhage from  ulcer,  486 

See,  Germain,  test-meal,  ill  ;  alkali  treat- 
ment, 325 

Sehrvv^ald,  physiology  of  cells,  24 

Seifert,  the  mouth  in  gastritis,  432 

Senator,  asthma  dyspepiicum,  367  ;  gastri- 
tis parasitaria,  416 

Senn,  N.,  gastric  distention  with  hydrogen, 
351  ;    bone-plates,  352 

Sieber,  bacteria  in  the  digestive  economy, 
63  ;   contents  of  ileum,  68 

Sievers,  gastiic  motor  function,  72 

Silbermann,  asthma  dyspepticum,  364 ; 
ulcer,  465 

Simon,  Chas.  E. ,  indican  in  gastric  dis- 
eases, 188;  HCl  therapy,  320  ;  urine 
in  stomach  diseases,  386 

Smith,  E.  E. ,  neurasthenia  gastrica,  762 

Sohlern,  von,  carbohydrates  vs.  proteids  in 
hyperacidity,  188 

Sohnan,  gastric  functions  affected  by  surgi- 
cal operations,  344 

Spalteholz,  gastric  anatomy,  17 

Stansfield,  gastro-enterostomy,  351 

Stern,  stomach  in  heart  disease,  372 

Stewart,  neuroses — electricity,  294  ;  anemia 
— gastric  atrophy,  747 

Stiller,  pylorospasm,  643  ;  nervous  vomit- 
ing, 655  ;  hunger,  700  ;  nervous  dys- 
pepsia, 759 

Stintzing,  dietetics,  194 

Stockton,  Chas.  G. ,  neuroses — electricity, 
294 

Strauss,  Herman,  total  acidity,  113  ;  gas- 
tric secretion,  140 ;  lactic  acid  test, 
160 

Streit,  gastric  operations,  343 

Strieker,  ulcer,  463 

Strobe,  carcinoma — mitosis,  528 

Strijmpell,  asthma  dyspepticum,  365 

Swieten,  von,  dilatation,  193 

Swiezicki,  von.  cell  physiology,  24 

Swiezynski,  antiperistalsis,  204 


T. 

Talma,  hyperesthesia  toward  HCl.  321 
Tanchou,  cancer — statistics,  508 
Tappeiner,  gastric  absorption,  92 
Thierfelder,  bacterial  relation  to  digestion, 

63 
Thomas,  T.  G. ,  intravascular  feeding,  209 
Thompson,  Gilman,  food  classes,  44,  45  ; 
dietetics,   185  ;   intravascular    feeding, 
209  ;   dietetics  of  alcohol,   274 ;   min- 
eral springs,  300,  et  seq. 
Tolma,  gastric  ulcer,  465 
Topfer,  free  HCl  estimation,  155 
Treheux,  acidity  of  the  urine  and   gastric 

contents,  713 
Trousseau,  gastric  vertigo,  360 
Turck,  F.  B.,  pyloric  intubation,  590 


U. 

Uffelman,  lactic  acid  test,  152;  dietetics, 
1S5 

V. 

Velden,  von  d.,  secretion,  gastric,  in  neo- 
plasms, 516 

Virchow,  erosions  of  mucosa,  125  ;  ulcer, 
464,  465  ;  splanchnoptosi.-',  603  ;  en- 
teroptosis,  605 

Vogel,  absorption  test,  95 

Voit,  bile,  60,  61  ;  rectal  alimentation,  201 


Waldeyer,  cancer,  505 

Weber,  guaiacum  test,  123  ;  electricity  as 
stimulus  to  peristalsis,  290 

Wegele,  dietetics,  185,  et  seq. 

Weir,  Robert  F. ,  gastrorrhaphy,  gastropli- 
cation,  453  ;   ulcer,  4S5 

Welch,  William  H.,  chronic  gastritis,  426  ; 
ulcer,  470,  471  ;  carcinoma,  5^3  j 
achylia  gastrica,   747 

Welti,  ulcer,  465 

Whitney,  Edward  L. .  gastric  absorption, 
96 ;  the  blood  and  urine  in  stomach 
diseases,  376-388  ;  gases  of  the  stom- 
ach, 380;  heterochylia,  763 

Whittaker,  subcutaneous  feeding,  210 

Widal,  acute  gastritis,  402 

Wiel,  dietetics,  185 

Williams,  pancreatic  juice,  67 

Winniwarter,  von,  surgical  treatment,  336 

Wisting,  von,  bile  function,  61 

Wittich,  bile,  60 

W'itzel,  gastrotomy,  339 

Woodruff,  C.  E.,  food  rations,  218 

Wolf,  1,.,  bitter  tonics  and  secretion,  327 

Wolfler,  surgery,  337,  347,  354 

Woltering,  dietetics,  185 


778 


LIST    OF    AUTHORS. 


Y. 

Yeo,  dietetics,  185  ;  food  energy,  217 
Yeo,  Burney,  gout  and  dyspepsia,  372 

Z. 

Zabludowsky,  massage,  296,  299 
Zawardski,  secretion  and  peristalsis  in  sur- 
gery, 344 


Zawardsky,  pancreatic  secretion,  57 
Zesas,  gastrostomy,  339,  533 
Ziegler,  acute  gastritis,  398,  410 
Ziemssen,     von,    gastric    secretion,    140 ; 
electricity  and  secretion,  289  ;   hydro- 
therapy, 295  ;    massage,   296  ;   gastri- 
tis, 448;   ulcer,  483 
Zweifel,  pancreas  diastase,  58  ;  gastric  ab- 
sorption, 91,  92 


LIST  OF  SUBJECTS. 


Compiled  by  tlie  Author's  pupil,  'Mr.  James  W.  Kissling  [Candid.  Aled. 


Abscess,  gastric  (see  Gastritis,  Phlegmon- 
ous) ;  subphrenic,  481 
Absorption :   of    various    substances,    66 ; 
dependence    on     the    motor 
function,     71,     90;     testing 
methods,  91  ;   a  conditioning 
factor  in  diet,  181,  183  ;   in- 
fluence of  alcohol,  280 
Acetic  acid :    intestinal  fermentation,  62  ; 

analysis,  154 
Acetone,  387 
Achlorhydria,  743 
Achroodextrin,  47,  48 
Achylia  gastrica  :  nature  and  concept,  743  ; 
symptoms,  749  ;    patho- 
logical   histology,    75 1 ; 
etiology,  754;  treatment, 

755 
Acidity :   as    affected    by    test-meals,    and 
climatic,    barometric,    and    geo- 
graphic factors,  112,  113  ;   of  the 
urine  and  gastric  contents,  713 
Acids:   acetic,  62,  154 

action  of  succus  entericus,  62 

amido,  44,  62 

asparaginic,  59 

aspartic,  59 

bile,  66  (detection  in  stomach  con- 
tents), 122 

butyric,  58,  62,  153 

caproic,  62 

carbonic,  62 

diacetic,  387 

fatty,  58,  62,  161 

free  (tests),  147 

hydrochloric      (see     Hydrochloric 
'  Acid) 

lactic,  62,  120,  151,  160,  529 

nitrogen-free  vegetable,  44 

organic,  free,  50 

total  (estimation),  161 

oxyacids,  62 

phenylacetic,  62 


Acids :  phenylpropionic,  62 
skatol  carbonic,  62 
stomach  acids  (anahsis),  155 
valerianic,  62 
Acoria,  705 
Adenocarcinoma,  492 
Adenoma,  pedunculated,  568 
Albumin,  acid  (see  Syntonin) 
Albuminoid  decomposition,  68 
Albuminous  substances    (see  Proteids  and 

Albumins) 
Albumins:   digestion — peptic,      49,      51  ; 
tryptic,  59  ;  influence 
on    biliary    secretion, 

60  ;  bile  action  on  al- 
bumins, 61  ;  relation 
to    succus    entericus, 

61  ;  in  treatment  of 
hypersecretion  and 
hyperacidity,  186— 
189,  239,  240 ;  in 
urine  the  result  of 
gastric  disorders,  387 

Albumoses,  63 

Alcohol :  in  food  substances,  44  ;  an  in- 
testinal fermentation  product, 
62  ;  gastric  absorbaljiiity  of,  66  ; 
dietetics,  274  ;  action  on  diges- 
tion— on  peptic,  276 ;  on  pan- 
creatic, 278 ;  salivar}-,  and  on  the 
motility,  279  ;  absorption  af- 
fected, 280  ;  summary  of  actions, 
280 ;  in  certain  pathological 
states,  281  ;  Sir  Wm.  Roberts' 
theory  in  respect  to  alcoholic 
retardation  of  digestion,  282 

Alimentation,  rectal  (see  Enemata,  Xutri- 
tive) 

Alkalies,  medicinal  agents,  322 

Alkalinity  of  the  blood,  378 

Alkaloids,  44 

Alveoli,  21 

Amidulin,  47,  48 

Ammonia,  62 

Amphopeptone,  5I)  59 


779 


78o 


LIST    OF    SUBJECTS. 


Amylaceous    foods    in    hyperacidity,    lS6- 
189,  239,  240,  723;  in 
hypersecretion,       239, 
240,  723 
Amylodextrin,  47,  48 
Amylolysis,  bile  in,  67 

hyperchylia,   its  influence  on, 

718 
pancreatic,  58 
ptyalic,  46-48,  61 
Amylopsin,  58,   67 
Anacidity  :  dietetics,  189  ;   indol  formation 

and  putrefaction,  320 
Anadenia  ventriculi,  743 
Analysis  :  stomach  contents — teclinic,  105  ; 
methods,       117;       quantitative 
chemical,  141  ;   of  gastric  juice, 
147  ;   of  stomach  acids,  155 
Anemia  and  gastnc  affections,  369,  482,  746 
Anorexia,    nervous:     dietetics,     182;     the 

clinic  of,  708 
Antipeptone,  59 
Antiperisialsis,  202-204 
Aniisepsisof  the  digestive  tract,  49,  65,  240 
Antizymotics  (see  agents  under  Aniiiepsis) 
Antrum  pylori,  18,  84 

Appetite,  anomalies  of  the  sensation  of,  700 
Asthma  dyspepticum,  364 
Atony : 

gastric,  myasthenic  :  terminology,  eti- 
ology, etc.,  573,  574, 
577  ;  diffeiential  diag- 
nosis, 587  ;  prognosis, 
590;  treatment,  dietetic, 
192,  198,  226,  228,  593, 
598  ;       medicinal,       etc., 

592.  594  .  . 
gastric,  neurotic :  definition  and  eti- 
olooy,  670-672  ;  symp- 
tomatology, 672-677  ; 
prognosis  and  diagnosis, 
677  ;  treatment,  678-682 
(ste  dietetic  under  Myas- 
thenic Type) 

Atresia,  591 

Atrophy  of  the  stomach,  743 

Auerbach,  plexus  of,  39 

Autochthonous  vegttation,  64 

Autodigestion,  gastric,  462 

Aut  )-intoxication,  intestinal,  65 


Bacteria  :  fermentation  and  putrefaction, 
58,  62,  63,  68,  69,  120;  eco- 
nomic and  pathogenic  signifi- 
cance, 63-65,  1 18-120  ;  species, 
62,  63,  70,  119,  415  ;  source  of 
food  for  the  colon  flora,  71  ; 
analysis  of  stomach  contents  for, 
118,  119;  HCl  and  peristalsis 
as    related    to    propagation     of, 


118;     products    giving    rise    to 
pathological  conditions,  1 20 
Bag,      intragastric,      stomach-shaped,     of 

Hemmeter,  77,  80-83,  ^9 
Basement  membrane,  35,  36 
Bile :    composition,    60 ;    uses    and   func- 
tions, 60,  61,  66,  67  ;  detection,  121 
Blood  :  supply  to  the  stomach,  29-31 

intestines,  33,  35,  38 
in    stomach  contents — tests,    122- 

124 
in  gastric  diseases,  376-380 
Boas"   method,  analysis  of  stomach  acids, 

159 
Braun's  method,  162 
Bulb  for  aspirating  test-meals,  107 
Bulimia :     dietetics,     181  ;     nature,     700 ; 
causation,    702  ;    symptomatol- 
ogy, 703  ;  diagnosis,  704  ;  treat- 
ment, 707 
Butyric  acid :   steapsin   digestion,    58  ;    in 
putrefaction,    62  ;    analysis, 
153 


Calcium,  44 
Cancer  (see  Carcinoma) 
Carbohydrates  :     economic    function,     44 ; 
effect  on  bile  efflux,  60  ; 
absorption  of,  in  presence 
of  bile,  6l;  fermentation, 
62,  63,  68  ;   action  of  the 
succus  entericus,  70  ;  in 
hyperacidity   and  hyper- 
secretion,  186-189,  239, 
240,  723 
Carbolic  acid,  62 
Carbon,  43 

Carcinoma:   blood  changes,   379;   pathol- 
ogy,    492  ;     etiology,     505  ; 
symptomatology,      514-526; 
diagnosis,     526-540;     treat- 
ment,   194,    231,    532,    534, 
536,    540 ;    prognosis,    541  ; 
differential      diagnosis      (see 
table),  546 
adeno-,  492 
colloid,  500 
duodenal,  523 
medullary,  495 
pancreas,  522 
ventriculi,  530 
scirrhous,  498,  499 
Cardia  :   anatomy  of  the,  17,  18 
cramp  of  the,  636 
incontinence  of  the,  660 
Cardiospasm,  636 
Caroid,  334 
Casein,  53,  59 

peptones,  59 
Catarrh,  gastric,  225,  226,  420 


LIST    OF    SUBIECTS. 


/' 


Cecum,  41 

Celiac  axis,  29 

plexus,  39 
Cells  :   acid,  24 

adelomorphous,  22,  23 

anilin  staining,  24 

border,  22,  23,  24,  27,  28 

central,  22-24,  27,  28 

chief,  22-24,  25,  26 

columnar  epithelial,  21,  33,  36 

cuboidal  epithelial,  21 

cylindrical  epithelial,  22 

delomorphous,  22,  23 

eosinophilic,  36 

epithelial  of  villi,  36,  61 

ferment,  24 

goblet,  36,  37  _ 

mucous  or  mucin,  21,  23,  26 

neoplasm,  527 

Nussbaum's  23 

oxyntic,  22,  23 

parietal,  22,  23 

pyloric  gland,  25 
Chlorids  :   in  gastric  HCI  production,  49, 

50 ;   in  urinary  changes,  383 
Chlorin,  44 

Chlorosis  and  gastric  diseases,  369 
Cholelithiasis,  480 
Chyme,  57,  60,  66,  67 
Cirrhosis  ventriculi,  421,  518 
Clinic,  the  gastric,  389 
Clysters  (see  Enemata) 
Colon,  41 

diaphany,  103 
Coloptosis.  620,  621 
Coma  carcinomatosum,  524 
Constipation,  chronic — dietetics,  236,  237 
Convulsions  of  the  pylorus,  643 
stomach,  645 
Cooking,  dieletical,  244 
Coprostasis,  606 

"  Corde  colique  transverse,"  613,  614 
Coronaria  ventriculi  artery,  31 
Cramp  of  the  cardia,  636 

pylorus,  643 
Creatin,  44 
Crises,  gastric,  653 
Cysts,  gastric,  569 

D. 

Deutero-albumose,  59 

Deuteroproteose,  51 

Dextrin  :    digestion  product — ptyalic,   47, 

48  ;   amyloptic,  58  ;    absorption 

of,  66 
Dextrose,  47-49 
Diabetes  mellitus  and  state  of  the  stomach, 

373 
Diagnosis,    differential,    of    cancer,    ulcer, 
gastralgia,    hyperchlorhydria,    and    gas- 
tritis (see  table),  546 

51 


Diaphany  of  stomach,  102 

duodenum,  103 
colon,  103 
ileum,  103 
Diarrhea,  chronic,  diet,  234,  236 
Diastase :    of  saliva,  46 ;   in  bile,   60 ;    of 
pancreas,  58,  67  ;   as  a  medici- 
nal agent,  330 
Diazo  reaction,  Ehrlich's,  3S8 
Dietetics:  historical  retrospect,  177  ;  diges- 
tibility,  178;    gastric   functions 
conditioning     diet — sensation, 
181  ;    absorption,    183  ;     secre- 
tion, 185  ;  motility,  192;  hyper- 
secretion and  hyperacidity,  1S6- 
189 ;     anacidity    or    subacidity, 
189;    ulcer,  186,  196;   gastritis 
acida,  1S6;    ulcus   carcinomato- 
sum, 186,  195  ;   atony  and  dila- 
tation,   192;     carcinoma,    194; 
neuroses,  198;   fattening  cures, 
198;    predigested   foods,    199; 
rectal  alimentation,  201  ;   intra- 
vascular and  hypodermic  feed- 
ing,   209 ;    tables  of    dietaries, 
211  ;    diet  lists,  219  ;    cooking 
of  food  and   the    palate,   241- 
245  ;     rectal    enemata,  varieties 
of,  272 ;   alcohol  and  alcoholic 
beverages,    274;     drinks     and 
liquid  foods,   245 
Diet  lists  :   Penzoldt's,    for     the     gradual 
training  of  the  digestive  capac- 
ity,  219 ;   Ewald's   and    Boas' 
lists,      223;       Hemmeter's  — 
chronic     gastritis,     etc. ,    223  ; 
Wegele's — chronic  catarrh,  225 , 
and  atony,  226  ;   Hemmeter's 
for      anacid     dilatation,    227  ; 
Wegele's — atony,     228  ;     car- 
cinoma,    231  ;      ulcer,     232 ; 
chronic  diarrhea,  234  ;  chronic 
constipation,   236  ;    hyperacid- 
ity, 237  ;   hypersecretion,  238  ; 
intestinal     antisepsis,     neuras- 
thenia, and  neuroses,  240  ;  and 
dyspepsia  on  hysterical   basis, 
241 
Digestion  :  alcohol   retardation  of,  theory 
of  SirWm.  Roberts,  282 
amylolytic,  46-48,  58,  61,  67 
fat,  58,  61 

intestinal,  53-71,  720 
pancreatic,  57—59,  278 
peptic,  49-53,  276,  281,  282 
proteolytic,  49-53,  59 
ptyalin,  46,  47,  61,  163,  279 
rennin,  53,  166,  167 
salivary,  46,  163,  279 
starch,  47,  48,  58,  61 
steapsin,  58 
tryptic,  59 


782 


LIST    OF    SUBJECTS. 


Dilatation,  gastric :  classification  and  no- 
menclature, 573 
obstructed  form,  574!  <iif" 
ferential  diagnosis,  5^^  '■< 
prognosis,  590  ;  treatment, 
192,  226-229,  595, 598 
atonic  form,  577 ;  differ- 
ential diagnosis,  588  ;  treat- 
ment,   192,   227,  228,  593, 

598 

Dilator  pylori,  20 

Diraetliyl-amido-azo-benzol  test,  I48 

Disinfection  of  digestive  tract,  49,  65,  240 

Divulsion,  digital,  of  the  pylorus,  349 

Douche,  the  gastric,  286 

Drinks  and  liquid  foods,  245 

Duodenodiaphany,  103 

Duodenal  intubation,  54-57 

secretions  :  interaction,  67  ;   de- 
tection, 122 

Duodenum,  32,  39 

Dyspepsia,  nervous  :  nature  and  concept, 
758;  pathology  and 
etiology,  759  ;  symp- 
tomatology, 7  60; 
prognosis,  762  ;  di- 
agnosis, 763  ;  hetero- 
chylia,  763  ;  differ- 
ential diagnosis,  764 ; 
treatment,  240,  765 


E. 

Elastin,  49,  59 

peptones,  49,  59 

Elastoses,  59 

Electric  stimulation  of  peristalsis,  80-83 

Electricity  in  gastric  therapy,  288,  et  seq. 

Electrode,  intragastric,  Einhorn's,  291 

Electrodiaphane,  103 

Electrodiaphany,  102— 104 

Enemata:  dilatation,  193,  194;  evolution 
of,  201  ;  ulcer,  197  ;  antiperis- 
talsis,  203,  204  ;  digestion  of, 
205  ;  preparation  and  adminis- 
tration, 207 ;  indications  for 
nutritive  kind,  208 ;  kinds  of 
nutritive,  272 

Enterodiaphany,  103 

Enteroptosis  :  etiology  and  symptomatol- 
ogy, 603-611  ;  treatijient, 
622 

Enzymes  (see  Ferments) 

Epileptiform  convulsions,  363 

Erosions,  gastric  — dietetic  treatment,  196 

Eructation,  nervous,  650 

Erythrodextrin,  47,  48 

Esophageal  applicator,  175 
forceps,  175 
tubal  probe.  III 

Esophagoscope,  175 


Ethereal  oils,  44 
Ewald  tube,  1 14 

Examination  of  stomach  patients — scheme, 
770 


Faradization,  293,  294 
Fasciae  teniae,  41 

Fats:   economic  import,  44 ;  in  pancreatic 
digestion,  58  :   effect  on  flow  of  bile, 
60  ;  bile  action,  61  ;   action  of  suc- 
cus  entericus,  61  ;  bacterial  action, 
62 
Fatty  acids  :   pancreatic  digestion,  58  ;  bac- 
terial product,    62 ;    analysis, 
161 
Feeding,  rectal  (see  Enemata,  Nutritive) 
Fermentation  :    relation   to   the   economy, 
63  ;   products,  62,  68  ;    in- 
hibiting   agents,    118;    in 
gastrectasia,  141 
Ferments  :   amylolytic,  46,  58,  61,  67,  163, 

330 

amylopsin,  58,  67 
artificial,  329 
bacteria  (see  Bacteria) 
diastatic,  46,  58,  60,  67,  330 
inverting  (of  succus  entericus), 

61 
milk  —  precipitating    (pancre- 
atic), 58 
pancreatic  diastase,  58 
pancreatin    (medicinal  agent), 

332 
pepsin  (see  Pepsin) 
pepsinogen  (see  Proenzymes) 
pineapple,  335 
proteolytic,  51,  58,  204 
prozymogen,  25,  26 
ptyalin,  46,  61,  163,  330 
rennin  (see  Rgnnin) 
rennin    zymogen    (see    Proen- 
zymes) 
steapsin,  58,  61 
trypsin,  59,  67,  69,  70,  71 
interaction,  66-71 
tests,  163 
in  urine,  388 
Fibromata,  565 

Food  substances  :   constituents,  and    their 
relation  to  the  economy, 
43  ;      food     groups    of 
Oilman  Thompson,  45 ; 
kinds    of  food   values, 
45  ;  combining    power 
with  HCl,  239  ;   drinks 
and  liquid  foods,  245 
Foreign  bodies  in  the  stomach,  569 
Fundus  of  stomach,  17 
Fungi  (see  Bacteria) 


LIST    OF   SUBJECTS. 


783 


G. 

Galvanization,  294 
Gases :   acetylene,  380 

carbonic  acid,  62,  380 
hydrogen,  43,  62,  380 
hydrogen  sulphid,  62,  380 
marsh,  380 
methyl  mercaptan,  62 
nitrogen,  380,  386 
oxygen,  380 
"stomach,"  141,  380 
Gastralgia  :   description,    692  ;     causation, 
693  ;  types,  695,  696  ;   symp- 
tomatology,   696  ;     diagnosis, 
697  ;     differential     diagnosis, 
546  ;  treatment,  699 
idiopathic,  695 
secondary,  696 
Gastralgokenosis,  700 
Gastrectasia  (see  Dilatation,  Gastric) 
Gastric  crises,  653 

diseases — influence  upon  other  or- 
gans and  metabolism,  358 
douche,  286 
idiosyncrasies,  691 
juice:     physiology,      22,     49-53; 
stimulations,    138  ;  chemi- 
cal examination,  147;  peri- 
odic atypical  flow  of,  727  ; 
chronic     continuous    flow, 
731 ;  absence  of  the  secre- 
tion, 743 
Gastritis,  definition    and    classification    of, 

389  . 
acute,  simple  :  nature  and  con- 
cept, 391  ;  etiology,394 ; 
pathological  histology, 
397  >  symptomatology 
and  course,  401  ;  diag- 
nosis, 403 ;  prognosis 
and  treatment,  404 ; 
condition  of  the  blood, 

379 
infectious  : 

G.   infectiosa,  413 
diphtheritica,  414 
mycotica,  414 
parasitaria,  415 
venenata,  416 
phlegmonous  or  purulent, 
409 
chronic  :  concept  and  types,  420 
simple  :  concept,  420  ;  eti- 
ology, 422  ;    pathologi- 
cal anatomy ,423  ;  symp- 
tomatology, 429 ;   com- 
plications. 437 ;  atypical 
forms,    438  ;  diagnosis, 
438  ;     prognosis,    440  ; 
differential      diagnosis, 


546;      treatment,    223, 
441  ;     blood    changes, 

379 

G.   acida,    436 ;    die- 
tetics,  186 
anacida,  435 
atrophicans,  435  ; 
state    of  blood, 
379;    diet,   223 
mucosa  or    muci- 

para,  435 
polyposa,  421 
syphilitic,  555 
Gastro-anastomosis,  354 
Gastrocolic  ligament,  41 
Gastrodiaphany  of  Einhorn,  102 
Gastrodynia  (see  Gastralgia) 
Gastro-enterostomy,  347 
Gastro-epiploic  arteries,  31 
Gastrograph  of  Einhorn,  579 

Hemmeter,  78,   80-83,  ^9 
Gastroliths,  569 
Gastromalacia,  462 

Gastroptosis,   611  ;  symptomatology,  620; 
diagnosis,    622,    587,    5^8; 
treatment,  622 
Gastrorrhaphy,  340 
Gastrorrhexis,  582 
Gastroscope,  171 
Gastroscopy,  1 70 
Gastrospasm,  645 
Gastrostomy,  338 
Gastrosuccorrhea  periodica,  727 
chronica,  731 
Gastrotomy,  338 
Gastroxie,  727 
Gastroxynsis,  727 
Gelatin,  49,  59,  61 

peptones,  49,  59 
Gelatoses,  59 
Glands:   agminate,  37,  38 
Brunner's,  37 
crypts  of  Lieberkiihn,  37 
gastric  follicles,  21,  22 
lymph  follicles,  37,  38 
mucous,  21 
peptic,  22,  23,  27 
Peyer's  patches,  37,  38 
pyloric,  27,  37 
salivary,  46 
solitary,  37,  38 
Glenard's  disease,  613 
Globulin,  59 
Glucosides,  44 
Glycerin,  58,  62 
Gmelin's  test,  121 
Gout  and  gastric  disease,  372 
Granulomatous  infections,  549 
Guaiacum  test,  122 
Gymnastics,  abdominal,  623 


784 


LIST    OF    SUBIECTS. 


H. 

Heart :     disturbances    induced    by   gastric 
diseases,  359 
cardiac     diseases     affecting     the 
stomach,  371 
Hehner-Seeman  method  of  analysis,  162 
Hemi-albumose  (see  Propeptone) 
Hemipeptone,  59 
Hemoglobin,  377 
Hepatocolic  ligament,  41 
Hepatoptosis,  613,  621 
Heterochylia,  763 
Heteroproteose,  51 
Hour-glass  stomach,  481,  591 
Hunger,  anomalies  of  the  sensation  of,  700 
Hydrochloric  acid :    source,  22-24,  27,  28, 
49 ;     derivation,     28, 
49  ;  action,  28,  49,  51, 
320 ;     demonstration, 
52  ;  in  gastric  antisep- 
sis, 64,  llS;    interac- 
tion among  secretions 
in  the  intestines,    66, 
67  ;      tests    for    HCl, 
free,    148,    combined, 
150 ;  combining  capa- 
city of  foods  with  acid, 
239  ;   effect  of  alcohol 
on  pepsin-hydrochlor- 
ic acid  digestion ,  276  ; 
as    medicinal     agent, 
316 ;     in     neoplasms, 
516;    in    hypersecre- 
tion, 733 
Hydrogen,  43,  62 
Hydronephrosis,  617 
Hydrotherapy,  295 

Hyperacidity:   true  index  of,  I14;  defini- 
tion  and  types,  187-189  ; 
factor    in    bulimia,    182 ; 
dietetics,     186-189,    237, 
238,       240  ;       combining 
power    of    various    foods 
with  HCl,  239  ;    relation 
to  indicanuria,  320  ;  factor 
in   ulcer,  466  ;    the  clinic 
of — characteristics,    71 1  ; 
nature  and  concept,  714  ; 
etiology,  715  ;   symptoma- 
tology,    717  ;      prognosis 
and  diagnosis,  721  ;    dif- 
ferential   diagnosis,    546 ; 
therapeutics.  723 
Hyperchlorhydria    (see  Hyperacidity) 
Hyperchylia  (see  H}-peracidity) 
Hyperesthesia,  688  ;  dietetics,  198 
Hypermotilit%"  as  factor  in  bulimia,  182 

the  clinic  of,  645 
Hyperorexia  (see  Bulimia) 


Hyperperistalsis,  645 
Hyperplasia,  inflammatory,  424 
Hypersecretion,    chronic,    731  ;    dietetics, 

186,  238,  240 
Hypochlorhydria,  739 
Hypochylia,  739 


Idiopathic  gastralgia,  695 
Idiosyncrasies,  gastric,  691 
Ileodiaphany,  103 
Ileum,  32,  41 
Inacidity,  nervous,  743 
Incontinence  of  the  cardia,  660 
pylorus,  667 
Indican,  63,  18S,  320 
Indicanuria,  320 
Indicators,  142,  144 
Indol,  59,  62,  320 
Inflammation  of  the  stomach,  suppurative 

(see  Gastritis,  Phlegmonous) 
Innutritious  materials  in  food  substances, 

43-  44 
Insufficiency  of  the  cardia,  660 
pylorus,  667 
stomach,    mechanical, 
670 
motor,  573 
Intestinal  digestion,  53-71,  118,720 

fermentation,  62,  63,  68,  1 18 
putrefaction,  61-63,  68,  69,  I18 
Intestine :    anatomy  of   small,   32-41 ;    of 
large,  41  ;    duodenal  intubation 
of  Hemmeter,  54-57  ;    entero- 
diaphany,    103  ;    auto-intoxica- 
tion and  disinfection,  65 
Intragastric  stomach-shaped  bag  of  Hem- 
meter,  77,  81 
Intubation,  duodenal,   of   Hemmeter,   54- 

57 
Inulin,  58 
Iron,  44,  123 
Ischochymia,  598 


Jejunum,  32,  41 


K. 


Karyokinesis  in  neoplasms,  527 

Kerkring,  valves  of,  34 

Kidneys :  diseases  of,  and  the  state  of  the 
stomach,  373 ;  dislocation  in 
gastroptosis  and  enteroptosis, 
606;  floating  and  movable, 
608  ;  palpation,  bimanual,  610  ; 
diagnosis  of  palpable,  movable, 
and  dislocated  kidney,  618 ; 
treatment,  625 


LIST    OF    SUBJECTS. 


785 


Lacteals,  23^  35 

Lactic   acid  :    intestinal  fermentation,  62  ; 
bacterial     gastric     product, 
120;     origin,     significance, 
and  detection,  15 1  ;   quanti- 
tative estimation,  160 ;   diag- 
nostic value  in  cancer,  529 
Lavage  :  double-current  stomach-tube,  105— 
107  ;   contra-indications,    108  ;    in 
dilatation,    193,   194;    indications 
for,  etc.,  285 
Leo's  method — analysis  stomach  acids,  159 
Leucin,  59,  62 
Leukocytosis,  377 
Levulose,  49 
Ligamenta  coli,  41 
Lipoma,  567 

Literature  :  on  the  history-  and  technics  of 
the  stomach-tube,  115  ;   exfoli- 
ations and  erosions  of  gastric 
mucosa,    127 ;     correlation  of 
diseases  of  the  stomach  to  those 
of  other   organs,   374 ;    acute 
and    chronic    gastritis,    453  ; 
phlegmonous    gastritis,    457  ; 
ulcer,  487  ;    carcinoma,  542  ; 
gastric  tuberculosis,  553  ;  gas- 
tric syphilis,  563  ;    dilatation, 
599 ;    gastroptosis   and   enter- 
optosis,   626  ;    neuroses,  6S2  ; 
chronic  gastrosuccorrhea,  738 
Liver  diseases  and  the  stomach,  372 
Lumbago,  620 
Lymphadenoma,  568 
Lymphangioma,  569 
Lymphatics  of  stomach,  30,  31  ;  intestines, 

33'  35>  39 
Lymph-corpuscles,  ameboid,  37 
Lymphoid  tissue,  35,  37 


M. 

Macrocytes,   482 

Magnesium,  44 

Malaria,  368 

Malformation  of  the  gastric  cavity,  591 

Maltose,  46-48,  58,  66 

Martins  and  Liittke's  method,  analysis 
stomach  acids,  157 

Massage,   296 

Materia  jNIedica,  177,  et  seq.,  316 

Meals,  test-,  111-114 

Medicinal  agents,  important :  HCl,  316  ; 
alkalies,  322 ;  bitter 
tonics,  326  ;  digestive 
ferments,  329 

Megalogastria,  573,  588 

Meissner,  plexus  of,  35,  39 

Melena  in  carcinoma,  525,  530 


]\Ierycism,  663 

^Mesenteric  plexus,  39 

Metabolism,  36,  358 

iMicrocytes,  482 

Miliary  tuberculosis,  550 

Mineral  springs,  300 

substances  of  food,  43 

Mitosis  in  gastric  tumors,  527 

Monobutyrin,  58 

Morgagni,  columns  of,  42 

^losquera  beef  meal,  190-192 

]Motor  function  (see  Peristalsis) 
insufficiency,  573 

Mucigen.  36 

Mucin,  61,  62 

Mucosa  :  structure — gastric,  21— 31  ;  intes- 
tinal, 33-39,42;  frag- 
ments in  wash-water 
and  vomit,  124— 128; 
diagnostic  s  i  g  n  i  fi  - 
cance  of  exfoliations 
and  erosions,  129; 
conductivity  with  ref- 
erence to  electricity, 
80-83,  292,  293 

ISIucous  membrane  (see  Mucosa) 

]Mucus,  21,  23,  25,  121 

Muscular  coat  of  stomach,  29  ;   of  intestine, 
32 

^luscularis  mucosse,  22,  33,  36 

^lyasthenia,  gastric  (see  Atony,  Gastric) 

INIyoma,  567 

^Myxoma,  571 


N. 

Neoplasms:   benign  tumors,   565 

granulomatous  infections,  549 
malignant  tumors,  492 
Nephritis  (see  Kidney  Diseases) 
Nephroptosis    (see    Kidneys,    Dislocation 

of  the) 
Nerves  of  the  stomach,  31 

intestine,  33,  35,  39 
Nervous  diseases  and  the  stomach,  368 
eructation,  650 

system  and  diseases  of  the  stom- 
ach, 360 
vomiting,  653 
Nessler's  reagent,  153 
Neurasthenia     gastrica     (see     Dyspepsia, 

Nervous) 
Neuroses,  gastric,  classification  of,  630 
dietetics  of,  198,  240 
general     considerations 

of,  631,  et  seq. 
motor,  636 
secretory,  71 1 
sensor)-,  688 
Nitrogen,  43,  386 
Nutrition  in  gastric  diseases,  358 


786 


LIST    OF    SUBJECTS. 


O. 

Obturator,  lf5 

Oligocythemia,  376 

Oliguria,  620 

Oppler-Boas  bacillus,  II9,  120,  529 

Organic  acids,  free,  50 

total — analysis,  161 
Orthopedic  treatment,  296 


Palpation,  97 
Pancreas,  57 

Pancreatic  digestion,  57-59,  278 
Fancreatin,  332 
Papain,  ^;i^ 
Papayotin,  233 
Papillomata,  565 
Papoid,  2S3 

Parasites,  animal,  and  gastritis,  416 
Pepsin :   source  and  origin,  22,  24,  27,  28, 
164;    action,   49,   51,   164,   167; 
tests,  52,  164,  165  ;  nature,  165  ; 
in   the   duodenum,   67 ;    ultimate 
fate  of,  69  ;    bile   action   on,  61  ; 
action  of  alcohol  on  pepsin-hydro- 
chloric acid,  276  ;  as  a  medicinal 
agent,  331 
Pepsinogen  (see  Proenzymes) 
Peptone:    peptic  product,    51  ;    test,   52; 
tryptic   product,    59;    bacterial 
product,     62 ;     absorption     of, 
66 ;  in  the  stools,  70 ;  peptone 
diet,  190 
Peptones :   casein,  59 

elastin,  49,  59 
gelatin,  49,  59 
Peptonuria,  387 
Percussion,  97 

Peristalsis:  influence  of  HCl,  49,  718; 
bile  influence,  61  ;  compara- 
tive importance,  71,90  ;  tests, 
72  —  90  ;  functions  of,  75  ; 
phases,  77,  84,  85  ;  passive 
movements,  79  ;  theories  re- 
lating to  the  movements  of 
the  gastric  ingesta,  S5-S9  ; 
electric  stimulation,  80-83 ! 
intragastric  pressure,  89;  fac- 
tor in  the  pathological  propa- 
gation of  micro-organisms, 
118;  relation  to  digestibility 
of  food  substances,  178,  181  ; 
antiperistalsis,  203,  204 ;  influ- 
ence of  alcohol,  279;  neuroses 
of,  636  ;   intestinal  peristalsis, 

33 
Peristaltic  unrest,  645 
Peritonitis,  perforation,  480 
Phenol,  62 

Phloroglucin-vanillin  test,  149 
Phosphates,  50,  384 


Phosphorus,  43,  44 
Phthisis  ventriculi,  743 
Phytobezoar,  572 
Pineapple  fennents,  335 
Pneumatosis,  651 
Pneumogastric  nerves,  31 
Poikilocytosis,  377,  482 
Polypi,  565 

Proenzymes,  pepsinogen  :   source,   23,  24, 
27,  165  ;  conversion  into 
pepsin,   27,  49,   51,   164 
164  ;  test,  165 
rennin  zymogen  :   source,  23, 
24 ;    conversion    into  rennin, 
49,  166;  test,  53,  167 
Prolapsus  of  the  stomach  (see  Gastroptosis) 
colon  (see  Coloptosis) 
spleen  (see  Splenoptosis) 
liver  (see  Hepatoptosis) 
Propepsin    (see  Pepsinogen  under  Proen- 
zymes) 
Propeptone,  51,  52 

Proteids  :   their  oflice  in  the  economy,  44  ; 
digestion — peptic,  49,  51,  167; 
tryptic,  59  ;  proteid  and  bile  in- 
teraction, 61  ;    intestinal  putre- 
faction,    62  ;     in    hyperacidity, 
186-189,  240,  718 
Proteolysis:   peptic,  49-53.    167;    trj'ptic, 
59;  in  hyperacidity,  186— 189, 
240,  718 
Proteoses,  51 
Protoproteose,  51 
Proz}-mogen,  25,  26 

Pt)"alin :  salivary  digestion,  46,  163;  of 
the  succus  entericus,  61  ;  alcohol 
action,  279  ;  an  artificial  ferment, 

330 
Pulmonary  diseases  and  the  stomach,  369 
Putrefaction :   bile    action,    61  ;    products, 
etc.,  62,  68;  economic  rela- 
tion, 63  ;  promoting  and  in- 
hibitory   agencies,     61,    69, 
118 ;      conjugate     sulphates 
and  indol,  indices  of,  320 
Pylorectomy,  340,  ef  seq. 
atypical,  345 
partial,  346 
Pyloric  ligaments,  18,  20 
spasm,  643 
valve,  18,   20 
Pyloroplasty,  348,  357 
Pylorospasm,  643 
Pylorus,  insufficiency  of,  667 
resection  of  the,  340 
spasm  of  the,  643 
Pyopneumothorax  subphrenicus,  4S1 


Rectum,  41 
Reflex  vomitins 


653.  656 


LIST    OF   SUBJECTS. 


787 


Regurgitation,  661 

Renal  diseases  (see  Kidney  Diseases) 

Rennin  :   source    and    derivation,    22,   24, 
166  ;  action,  53,  166  ;  action  de- 
stroyed, 68  ;  test,  53,  166 
zymogen  (see  Proenzymes) 

Resection  of  the  pylorus,  340;    statistics, 

354,  355.357 
Resorcin  test,  150 
Resorption  (see  Absorption) 
Respiration  in  stomach  diseases,  359 
Rest-cure,  Weir  Mitchell,  709 
Rheumatism  and  gastric  disease,  372 
Roentgen-ray  photography  of  the  stomach, 

589 
Rugee,  21 
Rumination,  663 

S. 

Saliva:  detection  in  gastric  contents,  121  ; 
nature  and  action,  46,  163  ;  influ- 
ence of  alcohol,  279 
Sarcinse,  1 19,  415 

Sarcomata,  51";  classification  and  etiology, 
511  —514;  symptomatology, 
514;  diagnosis,  518;  prognosis, 

541. 

Scirrhus,  gastric,  498 

Secretion  or  secretions  :  contemporaneous 
action  of,  66  ;  ad- 
mixtures of,  66 ; 
of  water  by  the 
stomach,  66 ; 
duodenal,  67, 
122  ;  in  the  fast- 
ing stomach, 
138 ;  dependence 
on  peristalsis,  71, 
90  ;  conditioning 
bacterial  propa- 
gation, n8  ;  fac- 
tor in  digestibility 
of  foods,  178, 
185  ;  in  neo- 
plasm, 516; 
neuroses  of,  71 1 

Self-digestion  of  the  stomach,  462 

Semilunar  ganglion,  39 

Sensation,  neuroses  of,  688 

Sensations  of  hunger  and  of  appetite, 
anomalies  of,  700 

Serous  coat  of  intestines,  32 

Sigmoid  flexure,  41 

Skatol,  62 

Skin  diseases  and  digestive  troubles,  374 

Sodium,  44 

Solar  plexus,  31 

Solutions,  standard  and  normal,  142 

Spasm,  pyloric,  643 

Spectroscopic  examination,  124 

Sphincter,  anal,  42  ;  pyloric,  20 


Splanchnoptosis,  603 
Splenoptosis,  621 
Spray,  intragastric,  287 
Starches,  46-48,  58 
Steapsin,  58,  61 

Stenosis,  hypertrophic  pyloric,  421 
cicatricial  pyloric,  480 
diet  in,  598 
Stomach  :    macroscopic    anatomy,   17-21  ; 
histology,  20-31 ;  location,  size, 
and  capacity — methods  for  de- 
termining these,  97-104 ;  stom- 
ach content  s — examination, 
105-128,   141  ;    acidity  in   the 
healthy  and  the  dyspeptic,  713; 
influence  of  its    diseases  upon 
other  organs  and    on  metabol- 
ism,   358 ;    influence    of    other 
affections  on  the  stomach,  368; 
the  blood  and  urine  in  gastric 
diseases,  376  ;  gases  141,380; 
the  clinic,  389,  et  seq. 
hour-glass,  481,  591 
pump,  1 13 
Stomach- tube  and  technics  of  its  introduc- 
tion, 1 05- 1 16 
Stomachic  remedies,  326 
Subacidity — dietetics,  189  ;  clinical,  739 
Submucosa  of  stomach,  21  ;   intestine,  ^iZ 
Succus  entericus,  61,  67,  70 
Sugar,  46,  60 
Sugars  :   cane,  49,  58,  66 
grape,  58,  66 
invert,  49,  58 
milk,  66 
Sulphates,  64,  320 
Sulphur,  43,  44 

Superacidity  (see  Hyperacidity) 
Supersecretion  (see  Hypersecretion) 
Surgery,   gastric  :     historical  review,    336  ; 
forms      of      operations, 
338  ;    fundamental    fac- 
tors in  mortality,  result- 
ing, 350 
Syntonin,  51,  66 
Syphilis  of  the  stomach,  554 


Telangiectatic  carcinoma,  493 

Test-meals,  111-114 

Tetanus,  363 

Tetany,  362 

Therapy  of  stomach  diseases  :  dietetics, 
177  ;  lavage  and  the  gastric 
douche,  285  ;  electricity, 
288 ;  hydrotherapeutic  and 
orthopedic  methods,  295  ; 
massage,  296  ;  mineral 
springs,  300  ;  important 
medicinal  agents,  316 


788 


LIST    OF    SUBJECTS. 


Titration,   142 

Tonics,  bitter,  326 

Topfer's  method  in  analysis,  155 

Tormina  ventriculi  nervosa,  645 

Transillumination  (see  Diaphany) 

Trypsin,  59,  67,  69,  70,  71 

Tr}'ptophan,  59 

Tube,  stomach-,  and  technics  of  its  intro 

duction,  105-I16 
Tuberculosis  of  the  stomach,  549-554 
Tumors,  benign,  565 

malignant,  492 

of  colon,  523 

of  gall-bladder,  522 

of  liver,  522 

of  omentum,  522 

of  peritoneum,  522 

splenic,  521 
Tyrosin,  59,  62 


Vagus  nerve,  39 

Valvulffi  conniventes,  33 

Vasa  brevia,  31 

Vermiform  appendix,  41 

Vertigo,  gastric,  360 

intestinal,  361 

Vigoral,  191 

Villi,  33,  34 

Viscera,  reversal  of  their  location,  619 

Vomiting,  cerebral,  central,  spinal,  653 
in  pregnancy,  633 
juvenile,  656 
nervous,  habitual,  653 
neurasthenic,  hysteric,  655 
periodical,  655 
reflex,  653,  656 


U. 

Ulcer  of  the  stomach  :  condition  of  the 
blood  in,  379  ; 
nature  of,  462 ; 
self-digestion  of 
stomach,  462; 
etiology,  465, 
,  467  ;  symptoma- 

tology, 473,514; 
diagnosis,  478, 
480 ;  differential 
diagnosis,  546  ; 
treatment,  186, 
196,  232-234, 
482 
carcinomatous,   186,  478,  481,  525, 

534_ 
syphilitic,  558 
tubercular,  55" 
Ulcus  ventriculi,  pepticum,  rotundum,  per- 
forans,  rodens,  corrosivum,  e  diges- 

tione,  462 
carcinomatosum  (see  Ulcer,  Carcin- 
omatous) 
Urea,  386 

Urine  :    in  gastric  diseases,  382  ;  acidity  in 
the  healthy  and  the  dyspeptic,  713 


W. 

Water  :   in  the  animal  economy,  43  ;  secre- 
tion and  absorption  in  the  stomach, 
66 
Waters,  natural,  mineral,  virtues  of,  300 
alkaline,  304,  306 
alkaline  sulphur,  305 
chalybeate,  306,  312, 

313 
acidulous,  306,  314 
saline,  307,  308 
sodium  chlorid,  307 
bitter    or     purgative, 

308,  309 
sulphuretted,  310-3 1 2 


Yeast  fungus,  1 19,  415 


Z. 

Zymogen  granules,  26 
Zymogens  (see  Proenzymes) 


CATALOGUE 
No.  1. 


READ  "SPECIAL  NOTE"  BELOW. 

APRIL,  1898. 


CATALOGUE 


EDicAL,  Dental, 

Pharmaceutical,  and  Scientific  Publications, 

WITH    A    SUBJECT    INDEX, 

OF  ALL  BOOKS  PUBLISHED  BY 

P.  BLAKISTON,  SON  &  CO. 

(Successors  to  Lindsay  &  Blakiston), 

PUBLISHERS,    IMPORTERS,    AND     BOOKSELLERS, 

IOI2  WALNUT  ST.,  PHILADELPHIA. 

SPECIAL   NOTE. 

The  prices  as  given  in  this  catalogue  are  absolutely  net,  no  discount  will 
be  allowed  retail  purchasers  under  any  consideration.  This  rule  has  been 
established  in  order  that  everyone  will  be  treated  alike,  a  general  reduction  in 
former  prices  having  been  made  to  meet  previous  retail  discounts.  Upon 
receipt  of  the  advertised  price  any  book  will  be  forwarded  by  mail  or  express 
all  charges  prepaid.  ' 

We  keep  a  large  stock  of  Miscellaneous  Books  relating  to  Medicine  and 
Allied  Sciences,  published  in  this  country  and  abroad.  Inquiries  in  regard  to 
prices,  date  of  edition,  etc.,  will  receive  prompt  attention. 


The  following:  Catalogues  sent  free  upon  application:— 

CATALOGUE  No.   1.— A  complete  list  of  the  titles  of  all  our  publications  on  Medicine. 

Dentistry,  Pharmacy,  and   Allied    Sciences,  with   Classified 
Index. 

CATALOGUE  No.  2.— Medical  Books.     Illustrated  with  portraits  of  prominent  authors 

and  figures  from  special  books. 
CATALOGUE  No.  3.— Pharmaceutical  Books. 
CATALOGUE  No.  4.— Books  on  Chemistry  and  Technology. 
CATALOGUE  No.   5.— Books  for  Nurses  and  Lay  Readers. 
CATALOGUE  No.  6. — Books  on  Dentistry  and  Books  used  by  Dental  Students. 
CATALOGUE  No.  7.— Books  on  Hygiene  and  Sanitary  Science;  Including  Water  and 

Milk  Analysis,  Microscopy,  Physical  Education,  Hospitals,  etc. 
SPECIAL  CIRCULARS. — Morris'  Anatomy  ;  Gould's  Medical  Dictionaries ;  Moullin's 

Surgery;   Books  on  the  Eye;  The  ?  Quiz  Compen'ds?  Series, 

Visiting  Lists,  etc.     We  can  also  furnish  sample  pages  of 

many  of  our  publications. 

P.  Blakiston,  Son  &  Co.'s  publications  may  be  had  through  booksellers  in  all  the 
principal  cities  of  the  United  States  and  Canada,  or  any  book  will  be  sent,  postpaid,  upon 
receipt  of  the  price,  or  forwarded  by  express,  C.  O.  D.  No  discount  can  be  allowed  retail 
purchasers  under  any  circumstances.  Money  should  be  remitted  by  express  or  post-office  money 
order,  registered  letter,  or  bank  draft. 


THE  PRICES  OF  ALL  BOOKS  ARE  NET. 


CLASSIFIED  LIST,  WITH  PRICES, 

OF  ALL  BOOKS  PUBLISHED  BY 

P.  BLAKISTON,   SON   &  CO.,   PHILADELPHIA. 

When  the  price  is  not  given  below,  the  book  is  out  of  print  or  about  to  be  published. 
Cloth  binding,  unless  otherwise  specified.     For  full  descriptions  see  following  Catalogue. 


ANATOMY. 
Ballou.     Veierinarj'  Anat.      Jo. 80 
Campbell.     Dissector.         -     i.oo 
Gordinier.  Anatomy  of  Nerv- 
ous System.       ...       

Heath.  Practical.  7th  Ed.  4.25 
Holden.  Dissector.  -  2.50 

Osteology.    -        -  5.25 

Landmarks.     4th  Ed.    i.oo 

Macalister's  Text-Book.  -  5.03 
Marshall's    Phys.  and  Anat. 

Diagrams.  40.00  and  60.00 

Morris.  Te.\t-Bookof.  791  lUus. 

Clo  ,  6.00;  Sh.,  7.00;  Yi  Rus.,  8.00 
Potter.       Compend  of.       5th 

Ed.     133  Illustrations.  -  .80 

Wilson's  Anatomy,  nth  Ed.  5.00 
^A^indle.     Surface  Anatomy,     i.oo 

ANESTHETICS. 

Buxton.     Anaesthetics.   -         

Turnbull.     4th  Ed.  -         2.50 

BRAIN  AND  INSANITY. 
Blackburn.     Autopsies.     -       1.25 
Gowers.      Diagnosis   of  Dis- 
eases of  the  Brain.     2d  Ed.      1.50 
Horsley.  Brain  and  S.  Cord.    2.50 
Ireland.     Mental   Diseases  of 

Children.  ...        

Lewis   (Sevan).     Mental 

Diseases.     2d  Ed.  -  

Mann's  Psychological  Med.  3.00 
Regis.  Mental  Medicine.  -  2.00 
Stearns.  Mental  Dis.  lUus.  2.75 
Tuke.  Dictionary  of  Psycho- 
logical Medicine.  2  Vols.  10.00 
Wood.     Brain  and  Overwork.     .40 

CHEMISTRY. 
See  Technological  Books,  Water. 
Allen,     Commercial    Organic 
Analysis.  2d  Ed.  Volume  I.  

Volume  II.  -         -         

Volume  III.     Part  I.   

Volume  III.     Part  II.  4.50 

Volume  III.  Fart  III.  4.50 

Volume  III.    Part  IV. 

Bartley.     Medical  and  Phar- 
maceutical.    4th  Ed.       -        2.75 

Bloxam's  Text-Book.  SthEd.  4.25 
Caldwell.      Qualitative    and 

Quantitative  Analysis.        -     1.50 
Clowes.    Qual.  Analysis.      -     1.25 
Groves  and  Thorp.     Chemi. 
cal  Technology    Vol.  I.  Fuels  5.00 

Vol.  11.     Lighting.      -     4.00 

Holland.    Urine,  Gastric  Con- 
tents, Poisons  and  Milk  Anal- 
ysis. 5th  Ed.         ...     I.oo 
Leffmann's  Compend.         -      .80 

Progressive  Exercises,  i.oo 

Milk  Analysis.    -       -     1.25 

Structural  Formulae.  -     i.co 

Muter.  Pract.  and  Anal.  1.25 
Oettel.     Electro-Chem.        .       .75 

Electro-Chem.  Exper.        .75 

Richter's  Inorganic.   4th  Ed.    1.75 

Organic.     2d  Ed.  4.50 

Smith.     Electro-Chem.  Anal.  1.25 
Smith  and  Keller.     Experi- 
ments.    3d  Ed.     Illus.  .60 

Stammer.  Chem.  Problems.  .50 
Sutton.  Volumetric  Anal.  4.50 
Symonds.  Manual  of.  2.00 
Woody.  Essentials  of.  4th  Ed. 

CHILDREN. 

Cautley.  Feeding  of  Infants.  2.00 
Hale.     Care  of.  .  .50 

Hatfield.     Compend  of.  .80 

Ireland.     Mental  Dis.  of.        

Meigs.     Milk  Analysis.   .  .50 

Money.     Treatment  of.    -  2.50 

Power.  Surgical  Diseases  of.  2.50 
Starr.    Digestive  Organs  of.       2.00 

Hygiene  of  the  Nursery,  i.oo 

Taylor  and  Wells.  Manual. 


.50 


.80 


.80 


CLINICAL  CHARTS. 
Griffiths.     Graphic.    Pads,     $0.50 
Keen.     Outline    Drawings    of 

Human  Body.        -        -  i.oo 

Schreiner.  Diet  Lists.  Pads,  .75 
Temperature  Charts.  Pads. 
COM  P  ENDS 
And  The  Quiz- Comiends . 
Ballou.  Veterinary  Anat. 
Brubaker's  Physiol.  8th  Ed. 
Gould  and  Pyle.  The  Eye. 
Hall.  Pathology.  Illus. 
Hatfield.  Children. 
Horwitz.  Surgery.  5th  Ed. 
Hughes.  Practice.  2  Pts.  Ea.  .80 
Landis.  Obstetrics.  5th  Ed.  .80 
Leffmann's  Chemistry.  4th  Ed.  .80 
Mason.     Electricity.        -  .75 

Potter's    Anatomy,   5th  Ed.       .80 

Materia  Medica.  6th  Ed.    .80 

Schamberg.  Skin  Diseases.  .80 
Stewart,  Pharmacy.  5th  Ed.  .80 
\A/arren.  Dentistry.  3d  Ed.  .80 
Wells.     Gynaecology.      -  .80 

CONSUM  PTION. 
Harris  and   Beale.      Pulmo- 
nary Consumption.      -        -     2.50 
Powell.      Diseases  of  Lungs, 

incluaing  Consumption.      -     4.00 
Tussey.    High  Altitude  Treat- 
ment of.        -        -        -        -     1.50 
DEFORMITIES. 
Reeves.      Bodily    Deformities 
and  their  Treatment.     Illus.   1.75 
DENTISTRY. 
Barrett.     Dental  Surg.    -  i.oo 

Blodgett.  Dental  Pathology.  1.25 
Flagg.     Plastic  Filling.  -  4.00 

Fillebrown.  Op.  Dent.  Illus.  2.25 
Gorgas.  Dental  Medicine.  4.00 
Harris.     Principles  and  Prac.  6.00 

Dictionary  of.     5th  Ed.  4.50 

Heath.     Dis.  of  Jaws.         -      4-50 

Lectures  on  Jaws.  Bds.    .50 

Richardson.  Mech.  Dent.  5.00 
Sewell.     Dental  Surg.       -        2.00 

Taft.    Operative  Dentistry.      

,  Index  of  Dental  Lit.       2.00 

Talbot.  Irregularity  of  Teeth.  3.00 
Tomes.     Dental  Surgery.  4.00 

Dental  Anatomy.  

AVarren's  Compend  of.     -  .80 

Dental    Prosthesis  and 

Metallurgy.     Illus.        -  1.25 

■White.    Mouth  and  Teeth.         .40 

DIAGNOSIS. 
Fenwick.    Medical.   SthEd.    2.50 

Tyson's  Manual.  3d  Ed.  Illus. 

DICTIONARIES. 
Gould's  Illustrated  Dictionary 
of  Medicine,  Biology,  and  Al- 
lied Sciences,  etc.     Leather, 
Net,   $10.00;     Half    Russia, 
Thumb  Index,        -        Net,  12  00 
Gould'sStudent's  Medical  Dic- 
tionary.    J^    Lea.,   loth    Ed., 
3.25  ;  ^  Mor., Thumb  Index.  4.00 
Gould's    Pocket     Dictionary. 
12,000  medical  words.    Lea., 
100:  Thumb  Index,       -         1.25 
Harris'  Dental.  Clo.  4.50 ;  Shp.  5.50 
Longley's  Pronouncing.  .75 

Maxwell.  Terminologia  Med- 
ica Polyglotta.  -    _     -        3-°° 
Treves.     German-English.        3.25 

EAR. 
Burnett.     Hearing,  etc.  .40 

Dalby.  Diseases  of.  4th  Ed.  2.50 
Hovell.     Treatise  on.  -     5. 00 

Pritchard.  Diseasesof.  3d  Ed.  1.50 
Woakes.        Deafness,    Giddi- 
ness, and  Noises  in  the  Head.  2.00 
ELECTRICITY. 
Bigelow.  Plain Talkson  Medi- 
cal Electricity.     43  Illus.  i.oo 


Mason's    Electricity  and    its 

Medical  and  Surgical  Uses.  $0.75 
Jones.       Medical    Electricity. 
2d  Ed.     Illus.  -        -        2.50 

EYE. 
Arlt.     Diseases  of.   -        -  1.25 

Donders.    Refraction.  -     

Fick.  Diseases  of  the  Eye.  4.50 
Gould  and  Pyle.  Compend.  0.80 
Gower's  Ophthalmoscopy.  4.00 
Harlan.     Eyesight.  -  .40 

Hartridge.  Refraction.  SthEd. 1.50 

Ophthalmoscope.  3d  Ed.  1.50 

Hansel!   and    Bell.    Clinical 

Ophthalmology.  120  Illus.  1.50 
Macnamara.  Diseases  of.  3.50 
Morton.     Refraction.  6th  Ed.  i.oo 

Ohlemann.   Ocular  Therap.    

Phillips.   Spectacles  and  Eye- 
glasses.    49  Illus.     2d  Ed.      I.oo 
Swanzy's  Handbook.  6th  Ed.  3.00 
Thorington.     Retinoscopy.      i.oo 
Walker.     Student's  Aid.  1.50 

FEVERS. 
Collie,  On  Fevers.    -  2.C0 

Goodall  and  Washbourn.     3.00 

HEADACHES. 
Day.     Their  Treatment,  etc.     i.oo 

HEALTH  AND  DOMESTIC 
MEDICINE. 
Bulkley.    The  Skin.         -  .40 

Burnett.     Hearing.  .  .40 

Cohen.  Throat  and  Voice.  .40 
Dulles.  Emergencies.  5th  Ed.  i.oo 
Harlan.     Eyesight.  -  .40 

Hartshorne,  Our  Homes,  .40 
Osgood.  Dangers  of  Winter.  .40 
Packarti.     Sea  Air,  etc.  .40 

Richardson's  Long  Life.  .40 

Westland.     The  Wife  and 

Mother.         ...  1.50 

White.  Mouth  and  Teeth.  .40 
^Vilson.  Summer  and  its  Dis.  .40 
AVood.     Overwork.  -  .40 

HISTOLOGY. 
Stirling.    Histology.    2d  Ed.  2.00 
Stbhr's  Histology.  Illus.      -     3.00 

HYGIENE. 
Canfield.   Hygiene  of  the  Sick- 

Room.      ...        -        1.25 
Coplin  and  Bevan.     Practi- 
I        cal  Hygiene.     Illus.        -        3.25 
Fox.     Water,  Air,  Food.  3.50 

I    Kenwood.      Public     Health 

Laboratory  Guide.  -         2.00 

Lincoln.     School  Hygiene.         .40 
McNeill.     Epidemics  and  Iso- 
lation Hospitals.      -        -        3.50 
Notter  and  Firth.  -        7.00 

Parkes' (E.).     See  "  Notter." 

(L.  C.),  Manual.  2.50 

Elements  of  Health.        1.25 

Starr.  H  ygiene  of  the  Nursery,  i.oo 
Stevenson  and  Murphy.  A 

Treatise  on  Hygiene.     In  3 
Vols.     Circular        Vol.  I,     6.00 
uion  application.     Vol.  II,    6.00 
Vol.  Ill,   s-oo 

Wilson's  Handbook.  8th  Ed. 

Weyl.     Coal-Tar  Colors,  1.25 

;  MASSAGE. 

'    Kleen  and  Hartwell.      -        2.25 

Murrell.     Massage.  6th  Ed.    

Ostrom.  Massage.  87  Illus.  i.oo 
Ward.    Noteson.  Paper  Gov.  i.oo 

MATERIA  MEDICA. 

Biddle.    13th  Ed.    Cloth,  4-00 

Bracken.     Materia  Med.  2.75 

i    Davis.     Essentials  of.  -     1.50 

Gorgas      Dental.     5th  Ed.       4.C0 

'    GrofF.    Mat.  Med  for  Nurses.  

Heller.     Essentials  of.  -     1.50 

Potter's  Compend  of.  5th  Ed.      .80 
I    Potter's  Handbook  of.    Sixth 
I        Ed.    Cloth,  4.50;  Sheep,        5.50 


ALL  PRICES  ARE  NET. 

CLASSIFIED  LIST  OF  P.  BLAKISTON,  SON  &-  CO:S  PUBLICATIONS. 


Sayre.   Organic  Materia  Med. 

and  Pharmacognosy.  -  ^4.00 
White  &  Wilcox.  Mat.  Med., 

Pharmacy,       Pharmacology, 

and    Therapeutics.     3d   Ed. 

Enlarged.    Cloth,  2.75;  Sh.    3.25 

MEDICAL  JURISPRUDENCE. 
Mann.     Forensic  Med.        -      6.50 
Reese.  Medical  Jurisprudence 
&Toxicology,5th  Ed  3.00;  Sh.  3.50 
MICROSCOPE. 
Beale.     How  to  Work  with.     6.50 

In  Medicine.  -  6.50 

Carpenter.    The  Microscope. 

7th  Ed.     800  Illus.  -        5.50 

Lee.  Vade  Mecum  of.  -  4.00 
MacDonald.     Examination  of 

Water  and  Air  by.  -  2.50 

Reeves.  Med.  Microscopy.      2.50 
Wethered.     Medical  Micros- 
copy.    Illus.        ...     2.00 
MISCELLANEOUS. 
Black.     Micro-organisms.  .75 

Burnet.  Food  and  Dietaries.  1.50 
Duckworth.  On  Gout.  -  6.00 
Garrod.  Rheumatism,  etc.  5.00 
Gould.  Borderland  Studies.  2.00 
Go^vers.  Dynamics  of  Life.  .75 
Haig.     Uric  Acid.  -        -    3.00 

Hare.  Mediastinal  Disease.  2.00 
Hemmeter.  Dis.  of  Stomach.  6.00 
Henry.  Anaemia.  -  -  .50 
Leffmann.  Coal  Tar  Products.  1.25 
Lizars.     On  Tobacco       -  .40 

Marshall.  Women's  Med.  Col.  1.50 
New  Sydenham  Society's 

Publications,  each  year.  -  8.00 
Parrish.     Inebriety.         -  i.oo 

St.  Clair.  Medical  Latin.  i.oo 
Sansom.  Dis.  of  Heart.  -  6.00 
Treves.     Physical  Education.    .75 

NERVOUS  DISEASES,  Etc. 
Beevor.     Nervous  Diseases.     2.50 
Gordinier.     Anatomy  of  Cen. 

tral  Nervous  System.      -        

Gowers.    Manual  of.     2d  Ed. 

530  Illus.  Vol.  1,3.00  ;  Vol.  2,4.00 

Syphilis  and  the  Ner- 
vous System.      ...      i.oo 

Diseases  of  Brain.  1.50 

Clinical  Lectures.  2.00 

Epilepsy.     New  Ed.      

Horsley.      Brain   and    Spinal 

Cord.  Illus.  -  -  -  2.50 
Obersteiner.   Central  Nervous 

System.    .         -        -         -  5.50 

Ormerod.     Manual  of.      -  i.oo 

Osier.     Cerebral  Palsies.  2.00 

^^^—  Chorea.           -          -  2.00 

Preston.     Hysteria.     Illus.  2.00 

Watson.     Concussions.  i.oo 

NURSING. 
Brown.  Physiology  for  Nurses.  .75 
Canfield.  Hygiene  of  the  Sick- 

Room.  ....  1.25 
Cuff.  Lectures  to  Nurses.  i.oo 
CuUingworth.    Manual  of.        .75 

Monthly   Nursing.  .40 

Domville's  Manual.  8th  Ed.  .75 
FuUerton.     Obst.  Nursing,      i.oo 

Nursing  in   Abdominal 

Surg,  and  Dis.  of  Women,  1.50 

Groff.    Mat.  Med.  for  Nurses. 

Humphrey.  Manual.  isthEd.  i.oo 
Shawe.  District  Nursing.  i.oo 
Starr.  Hygiene  of  the  Nursery,  i.oo 
Temperature  Charts.    -  .50 

Voswinkel.     Surg.  Nursing,   i.oo 

OBSTETRICS. 
Bar.     Antiseptic  Midwifery,      i.oo 
Cazeauxand  Tarnier.   Text- 
Book  of.     Colored  Plates.        4.50 
Davis.     Obstetrics.     Illus.       2.00 
Jellett.     Midwifery.         -  1.75 

Landis.  Compend.  5th  Ed.  .80 
Schultze.  Obstetric  Diagrams. 

20  Plates,  map  size.  Net,  26.00 
Strahan.  Extra-Uterine  Preg.  .75 
'Winckel's  Text-book.  5.00 


PATHOLOGY. 

Barlovv^.     General  Pathology. 

Blackburn.     Autopsies.  $1.25 

Blodgett.  Dental  Pathology  1.25 
Coplin.  Manual  of.  265  Illus.  300 
Gilliam.     Essentials  of.     -  .75 

Hall.  Compend.  Illus.  -  .80 
Virchow.     Post-mortems.  .75 

Whitacre.    Lab.  Text-book.    1.50 

PHARMACV 

Beasley's  Receipt-Book.      -  2.00 

Kormularj'.      -        -  2.00 

Coblentz.  Manual  of  Pharm.  3.50 

Proctor.     Practical  Pharm.  3.00 

Robinson.  Latin  Grammar  of.  1.75 
Sayre.    Organic  Materia  Med. 

and  Pharmacognosy.      .  4.00 

Scoville.     Compounding.  2.50 

Stewart's  Compend.  5th  Ed.  .80 
U.   S.   Pharmacopoeia.     7th 

Revision.  CI.  2.50  ;  Sh.,  3.00 

Select  Tables  from  U.S.  P.       .25 

PHYSIOLOGY. 
Brown.     Physiol,  for  Nurses.    .75 
Brubaker's  Compend.     Illus- 
trated.    8th  Ed.       -        -  .80 
Kirke's  New  14th  Ed.    (Halli- 

burtcn.)    Cloth,  3.00;     Sh.,  3.75 
Landois'  Text-book.  845  Illus- 
trations.        -        -  .        

Starling.  Elements  of.  .  i.oo 
Stirling.  Practical  Phys.  2.00 
Tyson's  Cell  Doctrine.  -  1.50 
Yeo's  Manual.  254  111.  6th  Ed.  2.50 

POISONS. 
Murrell.     Poisoning, 
Reese.    Toxicology.    4th  Ed.   3 
Tanner.     Memoranda  of. 

PRACTICE. 
Beale.    Slight  Ailments.  i 

Charteris,  Guide  to.         -  2 

Fowler's  Dictionary  of.      -      3 
Hughes.  Compend.  2  Pts.  ea. 

Physicians'  Edition. 

I  Vol.  Morocco,  Gilt  edge.     2.25 

Roberts.  Text-book,  gth  Ed.  4.50 
Taylor's  Manual  of.     -  2 

Tyson.    The  Practice  of  Medi- 
cine.   Illus.  CI.  5.50;  Sheep,  6 

PRESCRIPTION  BOOKS. 
Beasley's  3000  Prescriptions.   2 

Receipt  Book.        .  2 

Davis.     Materia   Medica  and 

Prescription  Writing.     -  1.50 

Pereira's  Pocket-book.  .75 

Wythe's  Dose  and  Symptom 

Book.     17th  Ed.     -       -       -    .75 

SKIN. 
Bulkley.    The  Skin.        -  .40 

Crocker.    Dis,  of  Skin.    Illus. 

Impey.  Leprosy.  -  .  3.50 
Schamberg.     Compend.  80 

Van   Harlingen.     Diagnosis 

and  Treatment  of  Skin  Dis. 

3d  Ed.     60  Illus.      -        -        2.75 

SURGERY  AND   SURGICAL 

DISEASES. 
Caird  and    Cathcart.     Sur- 
geon's Pocket-Book.      Lea.    2.50 
Deaver.     Appendicitis.        -     3.50 

Surgical  Anatomy.     .    

Dulles.     Emergencies.         -     i.oo 

Hamilton.    Tumors.    3d  Ed.  

Heath's  Minor.  loth  Ed.  1.25 
Diseases  of  Jaws.       -    4.50 

Lectures  on  Jaws.  .50 


3.00 
6.00 


Horwitz.  Compend.   5th  Ed. 

Jacobson.     Operations  of.   - 

Macready  on  Ruptures 

Maylard.     Surgery  of  the  Al 
mentary  Canal.         -         -         7.50 

Moullin.      Complete     Text- 
book     3d   Ed.  by  Hamilton, 
600  Illustrations  and  Colored 
Plates.  CI.  6.00;  Sh.    7.00 


Roberts'  Fractures.  -       $1.00 

Smith.  Abdominal  Surg.  10. co 
Swain.  Surgical  Emer.  -  1.75 
Voswinkel.  Surg.  Nursing,  i.oo 
■Walsham.  Practical  Surg.  2.00 
■Watson's  Amputations.  5.50 

TECHNOLOGICAL  BOOKS. 
Cameron.  Oils  &  Varnishes.    2.25 

Soap  and  Candles.         2.00 

Gardner.     Brewing,  etc.  1.50 

Gardner.     Bleaching    and 

Dyeing.    ...        -        1.50 
Groves  and  Thorp.    Chemi- 
cal   Technology.       Vol.     I. 
Mills  on  Fuels.         -         CI.  5-oo 
Vol.  II.     Lighting.           -          4.00 
Vol.  III.  Lighting  Contin'd. 

THERAPEUTICS. 
Allen,  Harlan,  Harte,  Van 

Harlingen.  Local  Thera.  3.00 
Biddle.     13th  Edition  -      4  00 

Field.  Cathartics  and  Emetics.  1.75 
Mays.     Theine.         -         -  5° 

Napheys'  Therapeutics.  Vol. 
I.  Medical  and  Disease  of 
Children.  -  Cloth,  4.00 

Vol.  2.  Surgery.  Gynsec. 

&  Obstet.  -  Cloth,  4.00 

Potter's  Compend.     5th  Ed.       .80 

,  Handbook  of.  4.50;  Sh.  5.50 

^Varing's  Practical.    4th  Ed.  2.C0 
White   and    Wilcox.     Mat. 
Med.,  Pharmacy,  Pharmacol- 
ogy, and  Thera.     3d  Ed.        2.75 

THROAT  AND  NOSE. 
Cohen.     Throat  and  Voice.         .40 
Hall.     Nose  and  Throat.     -      2.50 

Hutchinson.  Nose  &  Throat. 

Mackenzie.     Throat  Hospital 

Pharmacopoeia.  5th  Ed.  i.oo 
McBride.      Clinical  Manual, 

Colored  Plates.  2d  Ed.  -  6.00 
Potter.  Stammering,  etc.  i.oo 
Woakes.  Post-Nasal  Catarrh,  i.oo 

URINE  &  URINARY  ORGANS. 
Acton.     Repro.  Organs.  1.75 

Allen.     Diabetic  Urine.  2.25 

Brockbank.  Gail-Stones.  2.25 
Beale.  Urin.  Deposits.  Plates.  2.00 
Holland.  The  Urine,  Milk  and 

Common  Poisons.  5th  Ed.  i.oo 
Memminger.     Diagnosis  by 

the  Urine.     Illus.    -        -         i.oo 

Moullin.     The  Prostate.     -     

Thompson.  Urinary  Organs.  3.00 
Tyson.  Exam,  of  Urine.  1.25 
Van  Niiys.    Urine  Analysis,     i.oo 

VENEREAL  DISEASES. 
Cooper.  Syphilis.  2d  Ed.      -     5.00 
Gowers.      Syphilis  and    the 

Nervous  System.  -  -  i.oo 
Jacobson.     Diseases  of  Male 

Organs.     Illustrated.        -       6.00 

VETERINARY. 

Armatage.     Vet.  Rememb.  i.oo 

Ballou.'   Anat.  and  Phys.  8.0 

Tuson.     Pharmacopoeia.  2.25 

VISITING  LISTS. 
Lindsay  &  Blakiston's  Reg- 
ular Edition.  i.oo  to  2.25 

Perpetual  Ed.     1.25  to  1.50 

Monthly  Ed.         .75  to  1.00 

Send  J  or  Circular. 

WATER. 
Fox.     Water,  Air,  Food.  3.50 

Leffmann.  Examination  of.  1.25 
MacDonald.  Examination  of.  2.50 

WOMEN,  DISEASES  OF. 
Byford  (H.  T.).     Manual.   2d 

Edition.  341  Illustrations.  3.00 
Byford  (W^.  H).  Text-book.  2.00 
Diihrssen.     Gynecological 

Practice.  105  Illustrations.  1.50 
Lewers.  Dis.  of  Women.  2.50 
Wells.     Compend.     Illus.  .80 


IS=- BASED  ON  RECENT  MEDICAL  LITERATURE. 

Gould's  Medical  Dictionaries 

BY  GEORGE   M.  GOULD,  A.M.,  M.D., 

President,  1S93-94,  American  Academy  of  Medicine. 


THE  STANDARD  MEDICAL  REFERENCE  BOOKS. 


The   Illustrated   Dictionary  of  Medicine, 
Biology,  and  Allied  Sciences. 

INCLUDING  THE  PRONUNCIATION,  ACCENTUATION,  DERIVATION,  AND  DEFINITION 
OF  THE  TERMS  USED  IN  MEDICINE  AND  THOSE  SCIENCES  COLLATERAL  TO  IT  : 
BIOLOGY    (zoology   AND    BOTANY),   CHEMISTRY,    DENTISTRY,    PHARMACOLOGY, 

MICROSCOPY,  ETC.     With  many  Useful  Tables  and  numerous  Fine  Illustra- 
tions.    Large,  Square  Octavo.      1633  pages.     Third  Edition  now  ready. 
Full  Sheep,  or  Half  Dark-Green  Leather,  ^10.00;  with  Thumb  Index,  ^11.00 
Half  Russia,  Thumb  Index,  ^12.00 


The  Student's  Medical  Dictionary.  Tenth  Edition 

INCLUDING  ALL  THE  WORDS  AND  PHRASES  GENERALLY  USED  IN  MEDICINE,  WITH 
THEIR  PROPER  PRONUNCIATION  AND  DEFINITIONS,  BASED  ON  RECENT  MEDI- 
CAL LITERATURE.  With  Tables  of  the  Bacilli,  Micrococci,  Leucomains, 
Ptomains,  etc.,  of  the  Arteries,  Muscles,  Nerves,  Ganglia,  and  Plexuses; 
Mineral  Springs  of  the  U.  S.,  etc.     Small  Octavo.     700  pages. 

Half  Dark  Leather,  ^3.25  ;  Half  Morocco,  Thumb  Index,  ^4.00 

4®=" This  edition  has  been  completely  rewritten,  and  is  greatly  enlarged 
and  improved  over  former  editions. 

"  We  know  of  but  one  true  way  to  test  the  value  of  a  dictionary,  and  that  is  to  use  it.  We 
have  used  the  volume  before  us,  as  much  as  opportunity  would  permit,  and  in  our  search  have 
never  suffered  disappointment.  The  definitions  are  lucid  and  concise,  and  are  framed  in  the 
terms  supplied  by  the  latest  authoritative  literature,  rather  than  by  purely  philological  method. 
Obsolete  words  are  omitted,  and  this  has  made  the  dimensions  of  the  book  convenient  and  com- 
pact. In  making  a  dictionary,  the  author  confesses  that  he  has  found  out  the  labor  consists  in 
eliminating  the  useless,  rather  than  adding  the  superfluous.  The  value  of  the  work  before  us 
is  increased  by  the  large  number  of  useful  reference  tables  in  anatomy,  ptomains,  micrococci, 
etc." — The  Physician  and  Surgeon,  Ann  Arbor. 


The  Pocket  Pronouncing  Medical  Lexicon. 

12,000  "WORDS  PRONOUNCED  AND  DEFINED. 

Containing  all  the  Words,  their  Definition  and  Pronunciation,  that  the  Student 
generally  comes  in  contact  with ;  also  elaborate  Tables  of  the  Arteries, 
Muscles,  Nerves,  Bacilli,  etc.,  etc.;  a  Dose  List  in  both  English  and  Metric 
Systems,  etc.,  arranged  in  a  most  convenient  form  for  reference  and  mem- 
orizing. The  System  of  Pronunciation  in  this  book  is  very  sijnple.  Thin  64  mo. 
Full  Limp  Leather,  Gilt  Edges,  ^i.ooj  Thumb  Index,  $1.2'^. 


These  books  may  be  ordered  through  any  bookseller,  or  upon  receipt  of 
price  the  publishers  will  deliver  free  to  the  purchaser's  address.  Full  descriptive 
circulars  and  sample  pages  sent  free  tipon  application. 

76,000  COPIES  OF  GOULD'S  DICTIONARIES  HAVE  BEEN  SOLD. 


S^^  All  prices  are  net.     No  discount  can  be  allowed  retail  purchasers. 

P.  BLAKISTON,  SON  &  CO.'S 
]y[edical   and   l^cientific   publications, 

No.  IOI2  Walnut  St.,  Philadelphia. 


ACTON.  The  Functions  and  Disorders  of  the  Reproductive  Organs  in  Childhood, 
Youth,  Adult  Age  and  Advanced  Life,  considered  in  their  Physiological,  Social 
and  Moral  Relations.     By  Wm.  Acton,  m.d.,  m.r.c.s.    8th  Edition.     Cloth,  $1.75 

ALLEN,    HARLAN,   HARTE,  VAN   HARLINGEN.     Local   Therapeutics. 

A  Handbook  of  Local  Therapeutics,  being  a  practical  description  of  all  those 
agents  used  in  the  local  treatment  of  diseases  of  the  Eye,  Ear,  Nose,  Throat. 
Mouth,  Skin,  Vagina,  Rectum,  etc.,  such  as  Ointments,  Plasters,  Powders, 
Lotions,  Inhalations,  Suppositories,  Bougies,  Tampons,  and  the  proper  methods  of. 
preparing  and  applying  them.  By  Harrison  Allen,  m.d.,  Laryngologist  to  the 
Rush  Hospital  for  Consumption ;  late  Surgeon  to  the  Philadelphia  and  St. 
Joseph's  Hospitals.  George  C.  Harlan,  m.d.,  late  Professor  of  Diseases  of  the 
Eye  in  the  Philadelphia  Polyclinic  and  College  for  Graduates  in  Medicine ; 
Surgeon  to  the  Wills  Eye  Hospital,  and  Eye  and  Ear  Department  of  the 
Pennsylvania  Hospital.  Richard  H.  Harte,  m.d..  Surgeon  to  the  Episcopal 
and  St.  Mary's  Hospital;  Ass't  Surg.  University  Hospital;  and  Arthur  Van 
Harlingen,  m.d..  Professor  of  Diseases  of  the  Skin  in  the  Philadelphia  Poly- 
clinic and  College  for  Graduates  in  Medicine ;  late  Clinical  Lecturer  on  Derma- 
tology in  Jefferson  Medical  College ;  Dermatologist  to  the  Howard  Hospital.  In 
One  Handsome  Compact  Volume.    Cloth,  ^3.00;  Sheep,  1:4.00;  Half  Russia,  $5.00 

ALLEN.    Commercial  Organic  Analysis.    A  Treatise  on  the  Modes  of  Assaying 
the  Various  Organic  Chemicals  and  Products  employed  in  the  Arts,  Manufactures, 
Medicine,  etc.,  with  Concise  Methods  for  the  Detection  of  Impurities,  Adultera- 
tions, etc.     Second  Edition.    Revised  and  Enlarged.    By  Alfred  Allen,  f.c.s. 
Vol.  I.  Alcohols,  Ethers,  Vegetable  Acids,  Starch,  etc.  Ou^  of  Print. 

Vol.  II.  Fixed  Oils  and   Fats,  Hydrocarbons  and  Mineral  Oils,  Phenols  and 
their  Derivatives,  Coloring  Matters,  etc.  Out  of  Print. 

Vol.  Ill— Part  I.     Acid  Derivatives   of  Phenols,  Aromatic   Acids,  Tannins, 
Dyes,  and  Coloring  Matters.     8vo.  Out  of  Print. 

Vol.  Ill — Part  II.  The  Amines,  Pyridine  and  its  Hydrozines  and  Derivatives. 
The  Antipyretics,  etc.     Vegetable  Alkaloids,  Tea,  Coffee,  Cocoa,  etc.     8vo. 

Cloth,  $4.50 
Vol.  Ill — Part  III.     Vegetable  Alkaloids,  Non-Basic  Vegetable  Bitter  Princi- 
ples.   Animal  Bases,  Animal  Acids,  Cyanogen  Compounds,  etc.    Cloth,  $4.50 
Vol.  Ill — Part  IV.     The  Proteids  and  Albuminoid  Compounds.  In  Press. 

Chemical  Analysis  of  Albuminous  and  Diabetic  Urine.   Illus.  Cloth,  $2.25 

ARLT.  Diseases  of  the  Eye.  CHnical  Studies  on  Diseases  of  the  Eye.  Including  the 
Conjunctiva,  Cornea  and  Sclerotic,  Iris  and  Ciliary  Body.  By  Dr.  Ferd.  Ritter 
von  Arlt,  University  of  Vienna.  Authorized  Translation  by  Lyman  Ware, 
m.d..  Surgeon  to  the  Illinois  Charitable  Eye  and  Ear  Infirmary,  Chicago. 
Illustrated.     8vo.  Cloth,  $1.25 

ARMATAGE.  The  Veterinarian's  Pocket  Remembrancer:  being  Concise 
Directions  for  the  Treatment  of  Urgent  or  Rare  Cases,  embracing  Semeiology, 
Diagnosis,  Prognosis,  Surgery,  Treatment,  etc.  By  George  Armatage,  m.r.c.v.s. 
Second  Edition.     32mo.  Boards,  $i.co 

BALLOT!.  Veterinary  Anatomy  and  Physiology.  By  Wm.  R.  Ballou,  m.d., 
Prof,  of  Equine  Anatomy,  New  York  College  of  Veterinary  Surgeons,  Physician 
to  Bellevue  Dispensary,  and  Lecturer  on  Genito-Urinary  Surgery,  New  York 
Polyclinic,  etc.  With  29  Graphic  Illustrations.  i2mo.  No.  12  ?  Quiz- Compend f 
Series.  Cloth,  .80.     Interleaved,  for  the  addition  of  Notes,  $1.25 

5 


p.  BLAKISTON,  SON  6-  CO:S 


CALDWELL.  Chemical  Analysis.  Elements  of  Qualitative  and  Quantitative 
Chemical  i^nalysis.  By  G.  C.  Caldwell,  b.s.,  Ph.D.,  Professor  of  Agricultural 
and  Analytical  Chemistry  in  Cornell  University,  Ithaca,  New  York,  etc.  Third 
Edition.     Revised  and  Enlarged.     Octavo.  Cloth,  $1.50 

CAMERON.  Oils  and  Varnishes.  A  Practical  Handbook,  by  James  Cameron, 
F.LC.     With  Illustrations,  Formulae,  Tables,  etc.     i2mo.  Cloth,  %i.z^ 

Soap  and  Candles.     A  New  Handbook    for  Manufacturers,  Chemists,  Ana- 
lysts, etc.     54  Illustrations.     i2mo.  Cloth,  ^2.00 

CAMPBELL.  Outlines  for  Dissection.  To  be  Used  in  Connection  with  Morris's 
Anatomy.  By  W.  A.  Campbell,  m.d.,  Demonstrator  of  Anatomy,  University 
of  Michigan.     Octavo.  Cloth,  $1.00 

CANFIELD.  Hygiene  of  the  Sick-Room.  A  book  for  Nurses  and  others.  Being 
a  Brief  Consideration  of  Asepsis,  Antisepsis,  Disinfection,  Bacteriology,  Immu- 
nity, Heating  and  Ventilation,  and  kindred  subjects,  for  the  use  of  Nurses  and 
other  Intelligent  Women.  By  William  Buckingham  Canfield,  a.m.,  m.d., 
Lecturer  on  Clinical  Medicine  and  Chief  of  Chest  Clinic,  University  of  Mary- 
land, Physiciatj  to  Bay  View  Hospital  and  Union  Protestant  Infirmary,  Balti- 
more.    i2mo.  Cloth,  $1.25 

CARPENTER.  The  Microscope  and  Its  Revelations.  By  W.  B.  Carpenter, 
M.D.,  F.R.s.  Seventh  Edition.  By  Rev.  Dr.  Dallinger,  f.  r.  s.  Revised  and 
Enlarged,  with  '600  Illustrations  and  many  Lithographs.     Octavo,     iioo  Pages. 

Cloth,  $5.50 

CAUTLEY.  Feeding  of  Infants  and  Young  Children  by  Natural  and  Arti- 
ficial Methods.  By  Edmund  Cautley,  m.d.,  Physician  to  the  Belgrave  Hospital 
for  Children,  London.     i2mo.  Cloth,  $2.00 

CAZEATJX  and  TARNIER'S  Midwifery.    With  Appendix,  by  Munde.    The 

Theory  and  Practice  of  Obstetrics,  including  the  Diseases  of  Pregnancy  and 
Parturition,  Obstetrical  Operations,  etc.  By  P.  Cazeaux.  Remodeled  and  re- 
arranged, with  revisions  and  additions,  by  S.  Tarnier.m.d.  Eighth  American, 
from  the  Eighth  French  and  First  Italian  Edition.  Edited  by  Robert  J.  Hess, 
M.D.,  Physician  to  the  Northern  Dispensary,  Phila.,  etc.,  with  an  Appendix  by 
Paul  F.  Munde,  m.d..  Professor  of  Gynecology  at  the  New  York  Polyclinic. 
Illustrated  by  Chromo-Lithographs,  Lithographs,  and  other  Full-page  Plates 
and  numerous  Wood  Engravings.     8vo.  Cloth,  $4.50;  Full  Leather,  $5.50 

CHARTERIS.  Practice  of  Medicine.  The  Student's  Guide.  By  M.  Charteris, 
M.D.,  Professor  of  Therapeutics  and  Materia  Medica,  Glasgow  University,  etc. 
Sixth  Edition,  with  Therapeutical  Index  and  many  Illustrations.         Cloth,  $2.00 

CLOWES  AND  COLEMAN.  Elementary  Practical  Chemistry  and  Qualitative 
Analysis.  Adapted  for  Use  in  the  Laboratories  of  Schools  and  Colleges.  By 
Frank  Clowes,  d.Sc  ,  Professor  of  Chemistry,  University  College,  Nottingham, 
and  J.  Bernard  Coleman,  Demonstrator  of  Chemistry,  Nottingham,  England. 
54  Illustrations.  Cloth,  $1.25 

COBLENTZ.  Manual  of  Pharmacy.  A  Text-Book  for  Students.  By  Virgil 
Coblentz,  a.m.,  ph.g.,  PH.D.,  Professor  of  Theory  and  Practice  of  Pharmacy; 
Director  of  Pharmaceutical  Laboratory,  College  of  Pharmacy  of  the  City  of 
New  York.  Second  Edition,  Revised  and  Enlarged.  437  Illustrations.  Octavo. 
572  pages.  Cloth,  $3.50;  Sheep,  $4.50;  Half  Russia,  $5.50 

COHEN.  The  Throat  and  Voice.   By  J.  Solis-Cohen,  m.d.  Illus.  i2mo.    Cloth,  .40 

COLLIE,  On  Fevers.  A  Practical  Treatise  on  Fevers,  Their  History,  Etiology, 
Diagnosis,  Prognosis,  and  Treatment.  By  Alexander  Collie,  m.d.,  m.r.c.p., 
Lond.,  Medical  Officer  of  the  Homerton  and  of  the  London  Fever  Hospitals. 
With  Colored  Plates.     i2mo.  Cloth,  $2.00 


MEDICAL  AND  SCIENTIFIC  PUBLIC  A  TIONS.  9 

COOPER.  Syphilis.  By  Alfred  Cooper,  f.r.c.s.,  Senior  Surgeon  to  St.  Mark's 
Hospital ;  late  Surgeon  to  the  London  Lock  Hospital,  etc.  Edited  by  Edward 
COTTERELL,  F.R.C.S.,  Surgeon  London  Lock  Hospital,  etc.  Second  Edition. 
Enlarged  and  Illustrated  with  20  Full-Page  Plates  containing  many  handsome 
Colored  Figures.     Octavo.  Cloth,  $5.00 

COPLIN.  Manual  of  Pathology.  Including  Bacteriology,  the  Technic  of  Post- 
Mortems,  and  Methods  of  Pathologic  Research.  By  W.  M.  Late  Coplin,  m.d., 
Professor  of  Pathology  and  Bacteriology,  Jefferson  Medical  College  ;  Pathologist 
to  Jefferson  Medical  College  Hospital  and  to  the  Philadelphia  Hospital ;  Bacte- 
riologist to  the  Pennsylvania  State  Board  of  Health.  Being  the  Second  Edition 
of  the  author's  "Lectures  on  Pathology."  Rewritten  and  Enlarged.  265  Illus- 
trations, many  of  which  are  original.     i2mo.     638  pages.  Cloth,  $3.00 

COPLIN  and  SEVAN.  Practical  Hygiene.  By  W.  M.  L.  Coplin,  m.d.,  and  D. 
Bevan,  m.d.,  Ass't  Department  of  Hygiene,  Jefferson  Medical  College;  Bac- 
teriologist, St.  Agnes'  Hospital,  Philadelphia,  with  an  Introduction  by  Prof. 
H.  A.  Hare,  and  articles  on  Plumbing,  Ventilation,  etc.,  by  Mr.  W.  P.  Locking- 
ton.     138  Illustrations.     8vo. 

Cloth,  $3.25  ;  Sheep,  $4.25  ;   Half  Russia,  $5.25 

CROCKER.  Diseases  of  the  Skin.  Their  Description,  Pathology,  Diagnosis,  and 
Treatment,  with  special  reference  to  the  Skin  Eruptions  of  Children.  By  H. 
Radcliffe  Crocker,  m.d..  Physician  to  the  Dept.  of  Skin  Diseases,  University 
College  Hospital,  London.     92  Illustrations.     Third  Edition.  Preparing. 

CUFF.  Lectures  on  Medicine  to  Nurses.  By  Herbert  Edmund  Cuff,  m.d..  Late 
Ass't  Medical  Officer,  Stockwell  Fever  Hospital,  England.     With  25  Illustrations. 

Cloth,  1 1. 00 

CULLINGWORTH.    A  Manual  of  Nursing,  Medical  and  Surgical.    By  Charles 

J.  CULLINGWORTH,    M.D.,    Physician  to  St.  Thomas'   Hospital,  London.     Third 

Revised  Edition.     With  Illustrations.     i2mo.  Cloth,  .75 

A  Manual  for  Monthly  Nurses.    Third  Edition.    32mo.  Cloth,  .40 

DALBY.  Diseases  and  Injuries  of  the  Ear.  By  Sir  William  B.  Dalby,  m.d.. 
Aural  Surgeon  to  St.  George's  Hospital,  London.  Illustrated.  Fourth  Edition. 
With  38  Wood  Engravings  and  8  Colored  Plates.  Cloth,  $2.50 

DAVIS.  A  Manual  of  Obstetrics.  Being  a  complete  manual  for  Physicians  and 
Students.  By  Edward  P.  Davis,  m.d..  Professor  of  Obstetrics  and  Diseases  of 
Infancy  in  the  Philadelphia  Polyclinic,  Clinical  Lecturer  on  Obstetrics,  Jeffer- 
son Medical  College  ;  Professor  of  Diseases  of  Children  in  Woman's  Medical 
College,  etc.  Second  Edition,  Revised.  With  16  Colored  and  other  Lithograph 
Plates  and  134  other  Illustrations.     i2mo.  Cloth,  $2.00 

DAVIS.    Essentials  of  Materia  Medica  and  Prescription  Writing.    By  J. 

Aubrey  Davis,  m.d.,  Ass't  Dem.  of  Obstetrics  and  Quiz  Master  in  Materia 
Medica,  University  of  Pennsylvania;  Ass't  Physician,  Home  for  Crippled  Chil- 
dren, Philadelphia.     i2mo.  $1.50 

DAY.  On  Headaches.  The  Nature,  Causes,  and  Treatment  of  Headaches.  By 
Wm.  H.  Day,  m.d.     Fourth  Edition.     Illustrated.     8vo.  Cloth,  $1.00 

DOMVILLE.  Manual  for  Nurses  and  others  engaged  in  attending  to  the  sick.  By 
Ed.  J.  Domville,  m.d.  Eighth  Edition.  Revised.  With  Eecipes  for  Sick- 
room Cookery,  etc.     i2mo.  Cloth,  ,75 

DONDERS.  Aphorisms  Upon  Anomalies  of  Refraction,  and  Their  Results. 
Translated  and  Edited  by  Dr.  Herman  Snellen,  George  Berry,  Ophthalmic 
Surgeon,  Edinburgh  Royal  Infirmary,  and  Charles  A.  Oliver,  m.d.,  Philadel- 
phia.    Small  Octavo.  In  Press. 


10  p.  BLAKISTON,  SON  <&-  CO:S 

DEAVER.     Appendicitis.     Its  History,  Anatomy,  Etiology,  Pathology,  Symptoms 
Diagnosis,  Prognosis,  Treatment,  Complications,  and   Sequelae.      By  John   B" 
Deaver,  M.D.,  Assistant  Professor  of  Applied  Anatomy,  University  of  Pennsyl- 
vania;  Surgeon  to  the  German  Hospital,  to  the  Children's  Hospital,  and  to  the 
Philadelphia  Hospital;    Consulting  Surgeon  to  St.  Agnes',  St.  Tmiothy's,  and 
Germantown  Hospitals,  etc.    A  Systematic  Treatise,  with  Colored  Illustrations  of 
Methods  of  Procedure  in  Operatmg  and  Plates  of  Typical  Pathological  Condi- 
tions drawn  specially  for  this  work.     32  Full-Page  Plates.     8vo.  Cloth,  ^3.50 
Surgical  Anatomy.     A  Treatise  upon  Surgical  Anatomy  and  the  Anatomy 
of   Surgery.      Illustrated   by   upward   of  200   Original   Pictures   drawn    by 
special  artists  from  dissections  made  for  the  purpose.     Octavo.         In  Press. 

DUCKWORTH.  On  Gout.  Illustrated.  A  treatise  on  Gout.  By  Sir  Dyce 
Duckworth,  m.d.  (Edin.),  f.r.c.p.,  Physician  to,  and  Lecturer  on  Clinical 
Medicine  at,  St.  Bartholomew's  Hospital,  London.  With  Chromo-lithograohs 
and  Engravings.     Octavo.  Cloth,  $6.00 

DtJHRSSEN.  A  Manual  of  Gynecological  Practice.  By  Dr.  A.  Duhrssen, 
Privat-docent  in  Midwifery  and  Gynecology  in  the  University  of  Berlin.  Trans- 
lated from  the  Fourth  German  Edition  and  Edited  by  John  W.  Taylor,  f.r.c.s., 
Surgeon  to  the  Birmingham  and  Midlands  Hospital  for  Women  ;  Vice-President 
of  the  British  Gynecological  Society;  and  Frederick  Edge,  m.d.,  m.r.c.p., 
f.r.c.s..  Surgeon  to  the  Wolverhampton  and  District  Hospital  for  Women.  With 
105  Illustrations.     i2mo.  Cloth,  I1.50 

DULLES.  What  to  Do  First  In  Accidents  and  Poisoning.  By  C.  W.  Dulles,  m.d. 
Fifth  Edition,  Enlarged,  with  new  Illustrations.     i2mo.  Cloth.  $1.00 

FENWICK.  Guide  to  Medical  Diagnosis.  By  Samuel  Fenwick,  m.d.,  f.r.c.p., 
Consulting  Physician  to  the  London  Hospital;  and  W.  S.  Fenwick,  m.d., 
m.r.c.p.,  Physician  to  the  Out-Patients,  Evelina  Hospital  for  Children.  Eighth 
Edition.     In  great  part  rewritten,  with  several  new  chapters.     135  Illustrations. 

Cloth,  $2.50 

FICK.  Diseases  of  the  Eye  and  Ophthalmoscopy.  A  Handbook  for  Physicians 
and  Students.  By  Dr.-  Eugen  Fick,  University  of  Zurich.  Authorized  Transla- 
tion by  A.  B.  Hale,  m.d..  Ophthalmic  Surgeon,  United  Hebrew  Charities  ;  Con- 
sulting Ophthalmic  Surgeon,  Charity  Hospital,  Chicago;  late  Vol.  Assistant, 
Imperial  Eye  Clinic,  University  of  Kiel.  With  a  Glossary  and  158  Illustrations, 
many  of  which  are  in  colors.     Octavo. 

Cloth,  $4.50;  Sheep,  $5.50;  Half  Russia,  $6.50 

FIELD.  Evacuant  Medication — Cathartics  and  Emetics.  By  Henry  M.  Field, 
M.D.,  Professor  of  Therapeutics,  Dartmouth  Medical  College,  Corporate  Mem- 
ber Gynsecological  Society  of  Boston,  etc.     i2mo.     288  pp.  Cloth,  $1.75 

FILLEBROWN,  A  Text-Book  of  Operative  Dentistry.  Written  by  invitation 
of  the  National  Association  of  Dental  Faculties.  By  Thomas  Fillebrown,  m.d., 
D.M.D.,  Professor  of  Operative  Dentistry  in  the  Dental  School  of  Harvard  Uni- 
versity;  Member  of  the  American  Dental  Assoc,  etc.    Illus.    8vo.      Clo.,  $2.25 

FLAGG.  Plastics  and  Plastic  Fillings,  as  pertaining  to  the  filling  of  all  Cavities 
of  Decay  in  Teeth  below  medium  in  structure,  and  to  difficult  and  inaccessible 
cavities  in  teeth  of  all  grades  of  structure.  By  J.  Foster  Flagg,  d.d.s.,  Professor 
of  Dental  Pathology  in  Philadelphia  Dental  College.  Fourth  Revised  Edition. 
With  many  Illustrations.     8vo.  Cloth,  $4.00 

FOWLER'S  Dictionary  of  Practical  Medicine.  By  Various  Writers.  An  Ency- 
clopedia of  Medicine.  Edited  by  James  Kingston  Fowler,  m.a.,  m.d.,  f.r.c.p., 
Senior  Asst.  Physician  to,  and  Lecturer  on  Pathological  Anatomy  at,  the  Mid- 
dlesex Hospital,  London.     8vo.  Cloth,  I3.00 ;  Half  Morocco,  $4.00 

FOX.  Water,  Air  and  Food.  Sanitary  Examinations  of  Water,  Air  and  Food. 
By  Cornelius  B.  Fox,  M.D.    no  Engravings.    2d  Ed.,  Revised.        Cloth,  I3. 50 

GARDNER.    The  Brewer,  Distiller  and  Wine  Manufacturer.    A  Handbook  for 

all  Interested  in  the  Manufacture  and  Trade  of  Alcohol  and  Its  Compounds. 

Edited  by  John  Gardner,  f.c.s.     Illustrated.  Cloth,  $1.50 

Bleaching,  Dyeing,  and  Calico  Printing.  With  Formulae.    Illustrated.     $1.50 


MEDICAL  AND  SCIENTIFIC  PUBLIC  A  TIONS.  11 

JFULLEETON.     Obstetric  Nursing.     By  Anna  M.  Fullerton,  m.d.,   Demon- 
strator of  Obstetrics  in  the  Woman's   Medical  College ;    Physician    in    charge 
of,  and  Obstetrician  and  Gynecologist  to,  the  Woman's  Hospital,  Philadelphia, 
etc.  40  Illustrations.    Fourth  Edition.    Revised  and  Enlarged.   i2mo.  Cloth,  ^i.co 
BTursing  in  Abdominal  Surgery  and  Diseases  of  Women.    Comprising  the 
Regular  Course  of  Instruction   at  the   Training   School   of  the  Woman's 
Hospital,  Philadelphia.    Second  Ed.     70  Illustrations.     i2mo.     Cloth,  $1.50 

GAUROD.  On  Rheumatism.  A  Treatise  on  Rheumatism  and  Rheumatic  Arthritis. 
By  Archibald  Edward  Garrod,  m.a.  (Oxon.),  m.d.,  m.r.c.s.  (Eng.),  Asst. 
Physician,  West  London  Hospital.     Illustrated.     Octavo.  Cloth,  $5.00 

GILLIAM'S  Pathology.  The  Essentials  of  Pathology ;  a  Handbook  for  Students. 
By  D.  Tod  Gilliam,  m.d.,  Professor  of  Physiolog)^,  Starhng  Medical  College, 
Columbus,  O.    With  47  Illustrations.    i2mo.  Cloth,  .75 

GOODALL    and    WASHBOTJIIN.     A  Manual  of  Infectious   Diseases.     By 

Edward  W.  Goodall,  m.d.  (London),  Medical  Superintendent  Eastern  (Fever) 
Hospital,  Homerton,  London,  etc.,  and  J.  W.  Washbourn,  f.r.c.p.,  Assistant 
Physician  to  Guy's  Hospital  and  Physician  to  the  London  Fever  Hospital. 
Illustrated  with  Charts,  Diagrams,  and  Full-Page  Plates.  Cloth,  $3.00 

GORGAS'S  Dental  Medicine.  A  Manual  of  Materia  Medica  and  Therapeutics. 
By  Ferdinand  J.  S.  Gorgas,  m.d.,  d.d.s..  Professor  of  the  Principles  of  Dental 
Science,  Oral  Surgery  and  Dental  Mechanism  in  the  Dental  Dep.  of  the  Univ. 
of  Maryland.    Sixth  Edition.    Revised  and  Enlarged,  with  many  Formulae.    8vo. 

Cloth,  $4.00;  Sheep,  $5.00;   Half  Russia,  $6.00 

GOULD.    The  Illustrated  Dictionary  of  Medicine,  Biology,  and  AUied  Sciences. 

Being  an  Exhaustive  Lexicon  of  Medicine  and  those  Sciences  Collateral  to  it: 
Biology  (Zoology  and  Botany),  Chemistry,  Dentistry,  Pharmacology,  Microscopv, 
etc.      I3y  George  M.  Gould,  m.d..  Formerly  Editor   of   The  Medical  News ; 
President,  1893-94,  American  Academy  of  Medicine,  etc.     With  many  Useful 
Tables  and  numerous  Fine  Illustrations.     Large,  Square  Octavo.     1633  pages. 
Third  Edition  now  Ready.     Full  Sheep,  or  Half  Dark-Green  Leather,  ^10.00 ; 
With  Thumb  Index,  $11.00;  Half  Russia,  Thumb  Index,  $12.00 
The  Student's  Medical  Dictionary.    Tenth  Edition.    Enlarged.    Including 
all  the  Words  and  Phrases  generally  used  in  Medicine,  with  their  proper 
Pronunciation  and  Definitions,  based  on  Recent  Medical  Literature.     With 
Tables  of  the  Bacilli,  Micrococci,  Leucomains,  Ptomains,  etc.,  of  the  Arteries, 
Muscles,  Nerves,  Ganglia  and  Plexuses;   Mineral  Springs  of  U.  S.,  etc.    Re- 
written, Enlarged,  and  set  from  new  Type.     Small  octavo,  700  pages. 

Half  Dark  Leather,  $3.25;  Half  Morocco,  Thumb  Index,  $4.00 
The  Pocket  Pronouncing  Medical  Lexicon.  (12,000  Medical  Words 
Pronounced  and  Defined.)  A  Student's  Pronouncing  Medical  Lexicon. 
Containing  all  the  Words,  their  Definition  and  Pronunciation,  that  the 
Student  generally  comes  in  contact  with ;  also  elaborate  Tables  of  the 
Arteries,  Muscles,  Nerves,  Bacilli,  etc.,  etc.;  a  Dose  List  in  both  English 
and  Metric  System,  etc.,  arranged  in  a  most  convenient  form  for  reference 
and  memorizing.  Thin  64mo.  (6  x  3^  inches.)  The  System  of  Promttici- 
aiion  used  ifi  this  book  is  very  simple. 

Full  Limp  Leather,  Gilt  Edges,  $1.00;  Thumb  Index,  $1.25 
*^*  Sample  pages  and  descriptive  circulars  se7it  free  upon  application.    See  page  ^. 
Borderland  Studies.    Miscellaneous  Addresses  and  Essays  Pertaining  to  Medi- 
cine and  the  Medical  Profession,  and  Their  Relations  to  General  Science 
and  Thought.    By  George  M.  Gould,  m.d.    350  pages.    i2mo.    Cloth,  $2.00 
Compend  of  Diseases  of  the  Eye  and  Refraction.    Including  Treatment 
and  Operations,  with  a  Section  on  Local  Therapeutics.      By  George  M. 
Gould,  m.d.,  and  W.  L.  Pyle,  m.d.     With  Formulae,  Glossary,  and  several 
Tables,     in    Illustrations,   several    of  which    are    Colored.     Being  iV^.   8 
?  Quiz- Compend?  Series.  Cloth,  .80.     Interleaved  for  Notes,  $1.25 


12  P.  BLAKISTON,  SON  6^  CO.'S 

GORDINIER.  The  Gross  and  Minute  Anatomy  of  the  Central  Nervous 
System.  By  H.  C.  Gokdinier,  a.m.,  m.d.,  Professor  of  Physiology  and  Anatomy 
of  the  Nervous  System  in  the  Albany  Medical  College.  With  many  original 
Illustrations.  In  Preparatiofi. 

GRIFFITH'S  Graphic  Clinical  Chart.  Designed  by  J.  P.  Crozer  Griffith, 
M.D.,  Instructor  in  Clinical  r\Iedicine  in  the  University  of  Pennsylvania.  Printed 
in  three  colors.     Sample  copies  free.  Put  up  in  loose  packages  of  50,     .50 

Price  to  Hospitals,  500  copies,  $4.00;   1000  copies,  $7.50.     With  name  of  Hos- 
pital printed  on,  50  cents  extra. 

GROFF.  Materia  Medica  for  Nurses.  By  John  E.  Groff,  Pharmacist  Rhode 
Island  Hospital,  Providence.     i2mo.     200  pages.  In  Press. 

GROVES  AND  THORP.  Chemical  Technology.  A  new  and  Complete  Work. 
The  Applicadon  of  Chemistry  to  the  Arts  and  Manufactures.  Edited  by 
Charles  E.  Groves,  f.r.s.,  and  Wm.  Thorp,  b.sc,  f.i.c,  assisted  by  many 
experts.  In  about  eight  volumes,  with  numerous  illustrations.  Each  volume 
sold  separately. 

Vol.  I.    Fuel  AND  Its  Applications.     607  Illustrations  and  4  Plates.    Octavo. 

Cloth,  35.00;  Half  Morocco,  $6.50 
Vol.11.  Lighting.  Illustrated.  Octavo.  Cloth,  $4.00;  Half  Morocco,  §5. 50 
Vol.  III.     Lighting — Condnued.  In  Press. 

GOWERS.  Manual  of  Diseases  of  the  Nervous  System.  A  Complete  Text-book. 
By  William  R.  Gowers,  m.d.,  f.r.s.,  Physician  to  National  Hospital  for  the 
Paralyzed  and  Epileptic;  Consulting  Physician,  University  College  Hospital; 
formerly  Professor  of  Clinical  Medicine,  University  College,  etc.  Second 
Edition.  Revised,  Enlarged  and  in  many  parts  rewritten.  With  many  new 
Illustrations.     Two  Volumes.     Octavo. 

Vol.  I.    Diseases  of  the  Nerves  and  Spinal  Cord.    616  pages. 

Cloth,  33.00  ;  Sheep,  $4.00;   Half  Russia,  $5.00 

Vol.  II.     Diseases  of   the   Brain    and    Cranial    Nerves ;    General  and 
Functional  Diseases.    1069  pages. 

Cloth,  S4.00  ;  Sheep,  S5.00;  Half  Russia,  $6.00 
***This  book  has  been  translated  into  German,  Italian,  and  Spanish.      It  is 
published  in  London,  Milan,  Bonn,  Barcelona,  and  Philadelphia. 

Syphilis  and  the  Nervous  System.  Being  a  revised  reprint  of  the  Lettso- 
mian  Lectures  for  1890,  delivered  before  the  ^ledical  Society  of  London. 
i2mo.  Cloth,  Si.oo 

Diagnosis  of  Diseases  of  the  Brain.  8vo.  Second  Ed.  lUus.  Cloth,  Si. 50 
Medical  Ophthalmoscopy.  A  ^Manual  and  Atlas,  with  Colored  Autotype  and 
Lithographic  Plates  and  Wood-cuts,  comprising  Original  Illustrations  of  the 
changes  of  the  Eye  in  Diseases  of  the  Brain,  Kidney,  etc.  Third  Edition. 
Revised,  with  the  assistance  of  R.  Marcus  Gunn,  f.r.c.s..  Surgeon,  Royal 
London  Ophthalmic  Hospital,  Moorfields.     Octavo.  Cloth,  $4.00 

The  Djmamics  of  Life.    i2mo.  Cloth,  .75 

Clinical  Lectures.     A  new  volume  of  Essays  on  the  Diagnosis,  Treatment, 

etc.,  of  Diseases  of  the  Nervous  System.  Cloth,  $2.00 

Epilepsy  and  Other  Chronic  Convulsive  Diseases.  Second  Edition.  In  Press 
HAIG.  Causation  of  Disease  by  Dric  Acid.  A  Contribution  to  the  Pathology  of 
High  Arterial  Tension,  Headache,  Epilepsy,  Mental  Depression,  Gout,  Rheu- 
matism, Diabetes,  Bright's  Disease,  Anaemia,  etc.  By  Alex.  Haig,  m.a.,  m.d^ 
(Oxon.),  F.R.c  P.,  Physician  to  Metropolitan  Hospital,  London.  65  Illustrations. 
Fourth  Edition.  Cloth,  $3. 00 

BALE.    On  the  Management  of  Children  in  Health  and  Disease.       Cloth,  .50 

HALL.  Compend  of  General  Pathology  and  Morbid  Anatomy.  By  H.  Newbery 
Hall,  ph.g.,  m.u..  Professor  of  Pathology,  Post-Graduate  Medical  School, 
Chicago.     91  Illustrations.     A'o.  ij  ? Quiz- Compend  f  Series. 

New  Edition  Preparing^ 


MEDICAL  AND  SCIENTIFIC  PUBLICATIONS.  13 

HALL.  Diseases  of  tlie  Nose  and  Throat.  By  F.  De  Havillaxd  Hall,  m.d., 
F.R.c.p.  (Lond.),  Physician  in  charge  Throat  Department  Westminster  Hospital; 
Joint  Lecturer  on  Principles  and  Practice  of  ^Medicine,  Westminster  Hospital 
Medical  School,  etc.     Two  Colored  Plates  and  59  Illus.     i2mo.  Cloth,  $2.50 

HAMILTON.  Lectures  on  Tumors  from  a  Clinical  Standpoint.  By  John  B. 
Hamilton,  m.d.,  ll.d..  Professor  of  Principles  and  Practice  of  Surgery  and 
Clinical  Surgery  in  Rush  Medical  College,  Chicago;  Professor  of  Surgery, 
Chicago  Polyclinic ;  Surgeon  Presbyterian  Hospital,  etc.  Third  Edition, 
Revised  with  new  Illustrations.     i2mo.  Nearly  Ready. 

HANSELL  and  BELL.  Clinical  Ophthalmology,  Illustrated.  A  Manual  for 
Students  and  Physicians.  By  Howard  F.  Hansell,  a.m.,  m.d..  Lecturer  on 
Ophthalmology  in  the  Jefferson  College  Hospital,  Philadelphia,  etc.,  and  James 
H.  Bell,  m.d..  Ophthalmic  Surgeon,  Southwestern  Hospital,  Phila.  With 
Colored  Plate  of  Normal  Fundus  and  120  Illustrations.     i2mo.  Cloth,  §1.50 

HARE.  Mediastinal  Disease.  The  Pathology,  Clinical  History  and  Diagnosis  of 
Affections  of  the  Mediastinum  other  than  those  of  the  Heart  and  Aorta.  By  H.  A. 
Hare,  m.d..  Professor  of  .Materia  Medica  and  Therapeutics  in  Jefterson  Medical 
College,  Philadelphia.     8vo.     Illustrated  by  Six  Plates.  Cloth,  $2.00 

HARLAN.  Eyesight,  and  How  to  Care  for  It.  By  George  C.  Harlax,  m.d.. 
Prof,  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic.     Illustrated.         Cloth,  .40 

HARRIS'S  Principles  and  Practice  of  Dentistry.    Including  Anatomy,  Physi- 
olog)%  Patholog}',  Therapeutics,  Dental  Surgen,'  and  Mechanism.     By  Chapin  A. 
Harris,  m.d.,  d.d.s.,  late  President  of  the  Baltimore  Dental  College,  Author  of 
"  Dictionary'  of  Medical  Terminolog}'  and  Dental  Surger}\"     Thirteenth  Edition. 
Revised  and  Edited  by  Ferdinand  J.  S.  Gorgas,  a.m.,  m.d.,  d.d.s.,  Author  of 
"Dental    Medicine;"     Professor    of    the  Principles   of  Dental   Science,    Oral 
Burger}',  and  Dental  Mechanism  in  the  University  of  Mar^-land.     1250  Illustra- 
tions.   1 180  pages.     8vo.  Cloth,  $6.00;  Leather,  $7.00;  Half  Russia,  38.00 
Dictionary  of  Dentistry.     Fifth  Edition,  Revised.     Including  Definitions  of 
such  Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain  to  the  Art  and 
Practice  of  Dentistry.     Fifth   Edition.     Rewritten,  Revised  and  Enlarged. 
By  Ferdinand  J.  S.  Gorgas,  m.d.,  d.d.s..  Author  of  "Dental  Medicine;  " 
Editor  of  Harris's   "Principles  and    Practice  of  Dentistry';"  Professor  of 
Principles  of  Dental  Science,  Oral  Surgery,  and  Prosthetic  Dentistry  in  the 
University  of  Maryland.     Octavo.  Cloth,  $4-50  ;  Leather,  $5.50 
HARRIS  and  BEALE.    Treatment  of  Pulmonary  Consumption.    By  Vincent 
Dormer  Harris,  m.d.  (Lond.),  f.r.c.p..  Physician  to  the  city  of  London  Hospi- 
tal for  Diseases  of  the  Chest ;  Examining  Physician  to  the  Royal  National  Hos- 
pital for  Diseases  of  the  Chest,  Yentnor,  etc.,  and  E.  Clifford  Beale,  m.a., 
M.B.  (Cantab.),  f.r.c.p..  Physician  to  the  City  of  London  Hospital  for  Diseases 
of  the  Chest,  etc.     i2mo.  Cloth,  §2.50 
HARTRIDGE.    Refraction.     The  Refraction  of  the  Eye.     A  Manual  for  Students. 
By  GuSTAVUS  Hartridge,  F.R.C.S.,  Consulting  Ophthalmic  Surgeon  to  St.  Bar- 
tholomew's Hospital,  etc.     98  Illustrations    and   Test   Types.     Eighth    Edition. 
Revised  and  Enlarged  by  the  Author.  Cloth,  $1.50 
On  The   Ophthalmoscope.     A  Manual  for  Physicians  and  Students.     Third 
Edition.     With  Colored  Plates  and  68  Wood-cuts.     i2mo.  Cloth,  $1.50 

HARTSHORNE.  Our  Homes.  Their  Situation,  Construction,  Drainage,  etc.  By 
Henry  Hartshorne,  m.d.     Illustrated.  Cloth,  .40 

HATFIELD.  Diseases  of  Children.  By  Marcus  P.  Hatfield,  Professor  of 
Diseases  of  Children,  Chicago  Medical  College.  With  a  Colored  Plate.  Second 
Edition.     Being  No.  14,  f  Quiz- Competid  ?  Series.     i2mo.  Cloth,  .80 

Interleaved  for  the  addition  of  notes,  SI.25 

HELLER.  Essentials  of  Materia  Medica,  Pharmacy,  and  Prescription  Writ- 
ing. By  Edwin  A.  Heller,  m.d.,  Quiz-Master  in  Materia  Medica  and  Phar- 
macy at  the  Medical  Institute,  University  of  Pennsylvania.    i2mo.     Cloth,  $1.50 


14  P.  BLAKISTON,  SON  &>   CO:S 

HEATH.    Minor  Surgery  and  Bandaging.    By  Christopher  Heath,  f.r.c.s., 

Holme    Professor  of  Clinical    Surgery   in    University   College,  London.     Tenth 

Edition.      Revised  and   Enlarged.     With   158    Illustrations,  62   Formulae,  Diet 

List,  etc.     i2mo.  Cloth,  ;fi.25 

Practical  Anatomy.      A  Manual  of  Dissections.      Eighth  London  Edition. 

300  Illustrations.  Cloth,  $4.25 

Injuries  and  Diseases  of  the  Jaws.    Fourth  Edition.    Edited  by  Henry 

Percy   Dean,    m.s.,  f.r.c.s..  Assistant   Surgeon    London  Hospital.     With 

187  Illustrations.    8vo.  Cloth,  $4.50 

Lectures  on  Certain  Diseases  of  the  Jaws,  delivered  at  the  Royal  College  of 

Surgeons  of  England,  1887.     64  Illustrations.     8vo.  Boards,  .50 

HEMMETER.  Diseases  of  the  Stomach.  Their  Special  Pathology,  Diagnosis, 
and  Treatment.  With  Sections  on  Anatomy,  Analysis  of  Stomach  Contents, 
Dietetics,  Surgery  of  the  Stomach,  etc.  By  John  C.  Hemmeter,  m.d.,  philos.d., 
Clinical  Professor  of  Medicine  in  the  University  of  Maryland  ;  Consultant  to  the 
University  Hospital;  Director  of  the  Clinical  Laboratory,  etc.;  formerly  Clini- 
cal Professor  of  Medicine  at  the  Baltimore  Medical  College,  etc.  With  Colored 
and  other  Illustrations.  Cloth,  $6.00;  Leather,  $7.00;  Half  Russia,  $8.00 

HENRY.  Anaemia.  A  Practical  Treatise.  By  Fred'k  P.  Henry,  m.d.,  Physician 
to  Episcopal  Hospital,  Philadelphia.  Half  Cloth,  .50 

HOLDEN'S  Anatomy.  Sixth  Edition.  A  Manual  of  the  Dissections  of  the  Human 
Body.  By  John  Langton,  f.r.c.s..  Surgeon  to,  and  Lecturer  on  Anatomy  at, 
St.  Bartholomew's  Hospital.  Carefully  Revised  by  A.  Hewson,  m.d..  Demonstra- 
tor of  Anatomy,  Jefferson  Medical  College,  etc.  311  Illustrations.  i2mo.  800 
pages.  Cloth,  $2.50;  Oil-cloth,  $2.50;  Leather,  $3.00 

Human  Osteology.  Comprising  a  Description  of  the  Bones,  with  Colored 
Delineations  of  the  Attachments  of  the  Muscles.  The  General  and  Micro- 
scopical Structure  of  Bone  and  its  Development.  7th  Ed.,  carefully  Revised. 
With  Lithographic  Plates  and  Numerous  Illustrations.  Cloth,  I5.25 

Landmarks.     Medical  and  Surgical.     4th  Edition.     8vo.  Cloth,  |i. 00 

HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common  Poisons  and  the 
Milk.  Memoranda,  Chemical  and  Microscopical,  for  Laboratory  Use.  By  J.  W. 
Holland,  m.d..  Professor  of  Medical  Chemistry  and  Toxicology  in  Jefferson 
Medical  College,  of  Philadelphia.  Fifth  Edition,  Enlarged.  Illustrated  and 
Interleaved.   i2mo.  Cloth,  $1.00 

HORSLEY.  The  Brain  and  Spinal  Cord.  The  Structure  and  Functions  of.  Being 
the  Fullerian  Lectures  on  Physiology  for  1891.  By  Victor  A.  Horsley,  m.b., 
F.R.S.,  etc..  Assistant  Surgeon,  University  College  Hospital,  Professor  of  Pathology, 
University  College,  London,  etc.     With  numerous  Illustrations.  Cloth,  $2.50 

HORWITZ'S  Compend  of  Surgery,  including  Minor  Surgery,  Amputations,  Frac- 
tures, Dislocations,  Surgical  Diseases,  and  the  Latest  Antiseptic  Rules,  etc.,  with 
Differential  Diagnosis  and  Treatment.  By  Orville  Horwitz,  b.s.,  m.d..  Pro- 
fessor of  Genito-Urinary  Diseases,  late  Demonstrator  of  Surgery,  Jefferson  Medi- 
cal College.  Fifth  Edition.  Very  much  Enlarged  and  Rearranged.  Over  300 
pages.     167  Illustrations  and  98  Formulae.    i2mo.  A^o.g  ? Quiz- Compend?  Series. 

Cloth,  .80.     Interleaved  for  notes,  $1.25 

HOVELL.  Diseases  of  the  Ear  and  Naso-Pharynx.  A  Treatise  including 
Anatomy  and  Physiology  of  the  Organ,  together  with  the  treatment  of  the  affec- 
tions of  the  Nose  and  Pharynx  which  conduce  to  aural  disease.  By  T.  Mark 
HovELL,  F.R.C.S.  (Edin.),  M.R.C.S.  (Eng.),  Aural  Surgeon  to  the  London  Hospital, 
to  Hospital  for  Diseases  of  the  Throat,  etc.      122  Illus.      Octavo.      Cloth,  $5.00 

HUMPHREY.  A  Manual  for  Nurses.  Including  general  Anatomy  and  Physiology, 
management  of  the  sick-room,  etc.  By  Laurence  Humphrey,  m.a.,  m.b., 
M.R.C.S.,  Assistant  Physician  to,  and  Lecturer  at,  Addenbrook's  Hospital,  Cam- 
bridge, England.     Sixteenth  Edition.     i2mo.     Illustrated.  Cloth,  $1.00 


MEDICAL  AND  SCIENTIFIC  PUBLICATIONS.  15 

HUGHES.  Compend  of  the  Practice  of  Medicine.  Fifth  Edition.  Revised  and 
Enlarged.  By  Daniel  E.  Hughes,  m.d.,  Chief  Resident  Physician  Philadelphia 
Hospital ;  formerly  Demonstrator  of  Clinical  Medicine  at  Jefferson  Medical  Col- 
lege, Philadelphia.  In  two  parts.  Being  Nos.  2  and ^,  ? Quiz- Compend?  Series. 
Part  I. — Continued,  Eruptive  and  Periodical  Fevers,  Diseases  of  the  Stomach, 
Intestines,  Peritoneum,  Biliary  Passages,  Liver,  Kidneys,  etc.,  and  General 
Diseases,  etc. 

Part  II. — Diseases  of  the  Respiratory  System,  Circulatory  System  and  Ner- 
vous System  ;  Diseases  of  the  Blood,  etc. 

Price  of  each  Part,  in  Cloth,  .80  ;  interleaved  for  the  addition  of  Notes,  $1.25 
Physicians'  Edition. — In  one  volume,  including  the  above  two  parts,  a  sec- 
tion  on  Skin  Diseases,   and  an  index.      Fifth  revised,  enlarged  Edition. 
^68  pages.  Full  Morocco,  Gilt  Edge,  $2.25 

"  Carefully  and  systematically  compiled." — The  London  Lancet. 

HUTCHINSON.  The  Nose  and  Throat.  A  Manual  of  the  Diseases  of  the  Nose 
and  Throat,  including  the  Nose,  Naso-Pharynx,  Pharynx  and  Larynx.  By 
Procter  S.  Hutchinson,  m.r.c.s.,  Ass't  Surgeon  to  the  London  Hospital  for 
Diseases  of  the  Throat.  Illustrated  by  Lithograph  Plates  and  40  other  Illus., 
many  of  which  have  been  made  from  original  drawings.    i2mo.    2d  Ed.    In  Press. 

IMPEY.  A  Handbook  on  Leprosy.  By  S.  P.  Impey,  m.d.,  m.c,  Late  Chief  and 
Medical  Superintendent,  Robben  Island  Leper  and  Lunatic  Asylums,  Cape  Col- 
ony, South  Africa.     Illustrated  by  37  Plates  and  a  Map.     Octavo.      Cloth,  $3.50 

IRELAND.  The  Mental  Affections  of  Children.  Idiocy,  Imbecility,  Insanity, 
etc.  By  W.  W.  Ireland,  m.d.  (Edin.),  of  the  Home  and  School  for  Imbeciles, 
Mavisbush,  Scotland  ;  late  Medical  Supt.  Scot.  National  Institute  for  Imbecile 
Children  ;  Author  of  "  The  Blot  on  the  Brain,"  etc.     300  pages.  In  Press. 

JACOBSON.  Operations  of  Surgery.  By  W.  H.  A.  Jacobson,  b.a.  (Oxon.), 
F.R.C.S.,  (Eng.);  Ass't  Surgeon,  Guy's  Hospital;  Surgeon  at  Royal  Hospital  for 
Children  and  Women,  etc.     With  over  200  lUust.      Cloth,  $3.00  ;  Leather,  $4.00 

Diseases  of  the  Male  Organs  of  Generation.    88  Illustrations.    Cloth,  $6.00 

JELLETT.  The  Practice  of  Midwifery.  Embodying  the  Treatment  adopted  in 
the  Rotunda  Hospital,  Dublin.  By  Henry  Jellett,  b.a.,  m.d.,  Assistant  Master, 
Rotunda  Hospital,  with  a  Preface  by  W.  J.  Smyly,  m.d.,  f.r.c.p.i.,  Late  Master. 
With  many  Illustrations  and  an  Appendix  containing  Statistics  of  the  Hospital. 
i2mo.  Cloth,  ;^i.75 

JONES.  Medical  Electricity.  A  Practical  Handbook  for  Students  and  Prac- 
titioners of  Medicine.  By  H.  Lewis  Jones,  m.a.,  m.d.,  m.r.c.p..  Medical  Officer 
in  Charge  Electrical  Department,  St.  Bartholomew's  Hospital.  Second  Edition 
of  Steavenson  and  Jones'  Medical  Electricity,  Revised  and  Enlarged  112  Illus- 
trations.    i2mo.  Cloth,  $2.50 

KEEN.  Clinical  Charts.  A  series  of  seven  Outline  Drawings  of  the  Human  Body, 
on  which  may  be  marked  the  course  of  any  Disease,  Fractures,  Operations,  etc. 
By  W.  W.  Keen,  m.d..  Professor  of  the  Principles  of  Surgery  and  Clinical  Sur- 
gery, Jefferson  Medical  College,  Philadelphia.  Put  up  in  pads  of  50,  with 
explanations.  Each  pad,  ^i.oo.  Each  Drawing  may  also  be  had  separately 
gummed  on  back  for  pasting  in  case  book.     25  to  the  pad.     Price,  25  cents. 

*^*  Special  Charts  will  be  printed  to  order.     Samples  free. 

KIRKE'S  Physiology.  {14th  Authorized  Edition.  i2mo.  Dark  Red  Cloth.) 
A  Handbook  of  Physiology.  Fourteenth  London  Edition,  Revised  and  Enlarged. 
By  W.  D.  Halliburton,  m.d.,  f.r.s.,  Professor  of  Physiology  King's  College, 
London.  Thoroughly  Revised  and  in  many  parts  Rewritten.  661  Illus.,  many 
of  which  are  printed  in  Colors.    851  pages.     i2mo.    Cloth,  ^3.00  ;   Leather,  ^3.75 

IMPORTANT   NOTICE.     This  is  the  identical  Fourteenth  Edition  of  "  Kirke's  Physiology," 

as  published  in  London  by  John  Murray,  the  sole  owner  of  the  book. 

It  is  the  only  edition  containing  the  revisions  and  additions  of  Dr.  Halliburton,  and  the  new  and 
original  illustrations  included  at  his  suggestion.  It  is  the  edition  of  which  the  London  I,ancet 
speaks  in  its  issue  of  October  17,  i8g6,  as  follows  :  "  The  book  as  now  presented  to  the  student  may 
be  regarded  as  a  thoroughly  reliable  exposition  of  the  present  state  of  physiological  science." 


16  P.  BLAKISTON,  SON  <5-  CO:S 


KENWOOD.  Public  Health  Laboratory  Work.  By  H.  R.  Kenwood,  m.b., 
D.P.H.,  F.C.S.,  Instructor  in  Hygienic  Laboratory,  University  College,  late  Assistant 
Examiner  in  Hygiene,  Science  and  Art  Department,  South  Kensington,  London 
etc.     With  1 16  Illustrations  and  3  Plates.  Cloth   «;2.oo 

KLEEN.  Handbook  of  Massage.  By  Emil  Kleen,  m.d.,  ph.d.,  Stockholm  and 
Carlsbad.  Authorized  Translation  from  the  Swedish,  by  Edward  Mussey  Hart- 
well,  M.D.,  PH.D.,  Director  of  Physical  Training  in  the  Public  Schools  of  Boston 
\Vith  an  Introduction  by  Dr.  S.  Weir  Mitchell,  of  Philadelphia.  Illustrated 
with  a  series  of  Photographs  made  specially  by  Dr.  Kleen  for  the  American 
Edition.     8vo.  Cloth,  $2.25 

LANDIS'  Compend  of  Obstetrics  ;  especially  adapted  to  the  Use  of  Students  and 
Physicians.  By  HexVRY  G.  Landis,  m.d.  Fifth  Edition.  Revised  by  Wm.  H. 
Wells,  m.d.  ,  Ass't  Demonstrator  of  Clinical  Obstetrics,  Jefferson  Medical  CoUeo-e ' 
Member  Obstetrical  Society  of  Philadelphia,  etc.  Enlarged.  With  Many  Illus- 
trations.    No.  ^  ? Quiz- Compend  f  Series. 

Cloth,  .80;  interleaved  for  the  addition  of  Notes,  $1.25 

LANDOIS.  A  Text-Book  of  Human  Physiology  ;  including  Histolog}-  and  Micro- 
scopical Anatomy,  with  special  reference  to  the  requirements  of  Practical  Medi- 
cine. By  Dr.  L.  Laxdois,  Professor  of  Physiology  and  Director  of  the  Physio- 
logical Institute  in  the  University  of  Greifswald.  Fifth  American,  translated 
from  the  last  German  Edition,  with  additions,  by  Wm.  Stirling,  m.d.,  d.Sc, 
Brackenbury  Professor  of  Physiology  and  Histology  in  Owen's  College,' and  Pro- 
fessor in  Victoria  University,  Manchester  ;  Examiner  in  Physiology  in  University 
of  Oxford,  England.  With  845  Illustrations,  many  of  which  a're  printed  in 
Colors,     8vo.  In  Press. 

LAZARUS-BARLOW.  General  Pathology.  By  W.  S.  Lazarus-Barlow,  m.d., 
Demonstrator  of  Pathology  at  the  University  of  Cambridge,  England. 

hi  Preparaiio7i. 

LEE.  The  Microtomist's  Vade  Mecum.  Fourth  Edition.  A  Handbook  of 
Methods  of  Microscopic  Anatomy.  By  Arthur  Bolles  Lee,  formerly  Ass't  in 
the  Russian  Laboratory  of  Zoology,  at  Villefranche-sur-Mer  (Nice).  887  Articles. 
Enlarged  and  Revised,  and  in  many  portions  greatly  extended.    8vo.    Cloth,  §4.00 

LEFFMANN'S  Compend  of  Medical  Chemistry,  Inorganic  and  Organic.  In- 
cluding Urine  Analysis.  By  Henry  Leffmaxx,  m.d..  Prof,  of  Chemistry  in 
the  Woman's  Medical  College  in  the  Penna.  College  of  Dental  Surgery 'and 
in  the  Wagner  Free  Institute  of  Science,  Philadelphia ;  Pathological  Chemist 
Jefferson  Medical  College.  No.  10  ? Quiz- Compend?  Series.  Fourth  Edition. 
Rewritten.  Cloth,  .80.    Interleaved  for  the  addition  of  Notes,  $1.25 

The  Coal-Tar  Colors,  with  Special  Reference  to  their  Injurious  Qualities  and 
the  Restrictions  of  their  Use.     A  Translation  of  Theodore  W'evl's  Mono- 
graph. ^  i2mo.  Cloth,  $1.25 
Progressive  Exercises  in  Practical  Chemistry.    A  Laboratory  Handbook. 
Illustrated.      Third  Edition,  Revised  and  Enlarged.     i2mo.      Cloth.  Si.oo 
Examination  of  Water  for  Sanitary  and  Technical  Purposes.    Third  Edition. 
Enlarged.     Illustrated.     i2mo.                                                           Cloth,  %\.ik 
Analysis  of  Milk  and  Milk  Products.     Arranged  to  suit  the  needs  of  Analyt- 
ical Chemists,  Dairymen,  and  Milk  Inspectors.     Second  Edition,  Revised 
and  Enlarged,  with  Illustrations.     i2mo.                                            Cloth,  $1.25 
Handbook  of  Structural  Formulae  for  the  Use  of  Students,  containing  180 
Structural  and  Stereo-chemic  Formulee.     i2mo.     Interleaved.     Cloth,  $1.00 

LEWERS.  On  the  Diseases  of  Women.  A  Practical  Treatise.  By  Dr.  A.  H. 
N.  Lewers,  Assistant  Obstetric  Physician  to  the  London  Hospital;  and  Phy- 
sician to  Out-patients,  Queen  Charlotte's  Lying-in  Hospital;  Examiner  in  Mid- 
wifery and  Diseases  of  Women  to  the  Society  of  Apothecaries  of  London.  With 
146  Engravings.     Fifth  Edition,  Revised.  Cloth,  $2.50 

LINCOLN.    School  and  Industrial  Hygiene.    By  D.  F.  Lixcoln,  m.d.    Cloth,  .40 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  17 

LEWIS  (BEVAN).  Mental  Diseases.  A  text-book  having  special  reference  to  the 
Pathological  aspects  of  Insanity.  By  Bevan  Lewis,  l.r.c.p.,  m.r.c.S.,  Medi- 
cal Director,  West  Riding  Asylum,  Wakefield,  England.  i8  Lithographic  Plates 
and  other  Illustrations.     Second  Edition.     8vo.  In  Press. 

LIZARS  (JOHN).     On  Tobacco.     The  Use  and  Abuse  of  Tobacco.  Cloth,  .40 

LONGLEY'S  Pocket  Medical  Dictionary  for  Students  and  Physicians.  Giving 
the"  Correct  Definition  and  Pronunciation  of  all  Words  and  TeiTns  in  General 
Use  in  Medicine  and  the  Collateral  Sciences,  with  an  Appendix,  containing 
Poisons  and  their  Antidotes,  Abbreviations  Used  in  Prescriptions,  and  a  Tvletric 
Scale  of  Doses.     By  Elias  Longley.  Cloth,  .75  ;  Tucks  and  Pocket,  $1.00 

MACALISTER'S  Human  Anatomy.  800  Illustrations.  A  New  Text-book  for 
Students  and  Practitioners.  Systematic  and  Topographical,  including  the 
Embryology,  Histology  and  Morphology  of  Man.  With  special  reference  to  the 
requirements  of  Practical  Surgery  and  Medicine.  By  Alex.  Macalister,  m.d., 
F.R.S.,  Professor  of  Anatomy  in  the  University  of  Cambridge,  England.  816  Illus- 
trations.    Octavo.  Cloth,  $5.00 ;  Leather,  $6.co 

MACDONALD'S  Microscopical  Examinations  of  Water  and  Air.  With  an  Ap- 
pendix on  the  Microscopical  Examination  of  Air.  By  J.  D.  Macdonald,  m.d. 
25  Lithographic  Plates,  Reference  Tables,  etc.     Second  Ed.     8vo.      Cloth,  $2.50 

MACKENZIE.  The  Pharmacopoeia  of  the  London  Hospital  for  Diseases  of 
the  Throat.  By  Sir  Morell  Mackenzie,  m.d.  Fifth  Edition.  Revised  and 
Improved  by  F.  G.  Harvey,  Surgeon  to  the  Hospital.  Cloth,  $1.00 

MACNAMARA.  On  the  Eye.  A  Manual.  By  C.  Macnamara,  m.d.  Fifth 
Edition,  Carefully  Revised;  with  Additions  and  Numerous  Colored  Plates,  Dia- 
grams of  Eye,  Wood-cuts,  and  Test  Types.     Demi  8vo.  Cloth,  $3.50 

MACREADY.  A  Treatise  on  Ruptures.  By  Jonathan  F.  C.  H.  Macready, 
F.R.C.S.,  Surgeon  to  the  Great  Northern  Central  Hospital ;  to  the  City  of  London 
Hospital  for  Diseases  of  the  Chest ;  to  the  City  of  London  Truss  Society,  etc. 
With  24  full-page  Plates  and  numerous  Wood-Engravings.   Octavo.      Cloth,  $6.00 

MANN.  Eorensic  Medicine  and  Toxicology.  A  Text-Book  by  J.  Dixon  Mann, 
M.D.,  F.R.C.P.,  Professor  of  Medical  Jurisprudence  and  Toxicology  in  Owens  Col- 
lege, Manchester;  Examiner  in  Forensic  Medicine  in  University  of  London,  etc. 
Illustrated.     Octavo.  Cloth,  $6.50 

MANN'S  Manual  of  Psychological  Medicine  and  Allied  Nervous  Diseases.  Their 
Diagnosis,  Pathology,  Prognosis  and  Treatment,  including  their  Medico-Legal 
Aspects  ;  with  chapter  on  Expert  Testimony,  and  an  abstract  of  the  laws  relating 
to  the  Insane  in  all  the  States  of  the  Union.  By  Edward  C.  Mann,  m.d. 
With  Illustrations.     Octavo.  Cloth,  $3.00 

MARSHALL.  The  Woman's  Medical  College  of  Pennsylvania.  An  Historical 
Outline.     By  Clara  Marshall,  xM.d.,  Dean  of  the  College.     8vo.    Cloth,  $1.50 

MARSHALL'S  Physiological  Diagrams,  Life  Size,  Colored.  Eleven  Life-size 
Diagrams  (each  7  feet  by  3  feet  7  inches).  Designed  for  Demonstration  before 
the  Class.  By  John  Marshall,  f.r.s.,  f.r.c.s.,  Professor  of  Anatomy  to  the 
Royal  Academy  ;  Professor  of  Surgery,  University  College,  London,  etc. 

In  Sheets,  $40.00     Backed  with  Muslin  and  Mounted  on  Rollers,  $6o!oo 
Ditto,  Spring  Rollers,  in  Handsome  Walnut  W^all  Map  Case  (Send  for 

Special  Circular), $100.00 

Single  Plates,  Sheets,  $5.00;  Mounted,  $7.50;  Explanatory  Key,  50  cents. 
No.  I — The  Skeleton  and  Ligaments.  No.  2 — The  Muscles  and  Joints,  with 
Animal  Mechanics.  No.  3 — The  Viscera  in  Position.  The  Structure  of  the  Lungs. 
No.  4 — The  Heart  and  Principal  Blood-vessels.  No.  5 — The  Lymphatics  or  Absorb- 
ents. No.  6 — The  Digestive  Organs.  No.  7 — The  Brain  and  Nerves.  Nos.  8  and  9 — 
The  Organs  of  the  Senses.  Nos.  10  and  11 — The  Microscopic  Structure  of  the 
Textures  and  Organs.     {Send for  Special  Circular.') 


18  P.  BLAKISTON,  SON  <S-  CO:S 

MASON'S  Compend  of  Electricity,  and  its  Medical  and  Surgical  Uses.  By 
Charles  F.  Mason,  m.d.,  Assistant  Surgeon  U.  S.  Army.  With  an  Intro- 
duction by  Charles  H.  May,  m.d.,  Instructor  in  the  New  York  Polyclinic. 
Numerous  Illustrations.     i2mo.  Cloth,  .75 

MAXWELL.  Terminologia  Mediea  Polyg-lotta.  By  Dr.  Theodore  Maxwell, 
assisted  by  others  in  various  countries.     8vo.  Cloth,  $3.00 

The  object  of  this  work  is  to  assist  the  medical  men  of  any  nationality  in  reading  medical  literature  written 
in  a  language  not  their  own.  Each  term  is  usually  given  in  seven  languages,  viz. :  English,  French,  German, 
Italian,  Spanish,  Russian  and  Latin. 

MAYLARD.  The  Surgery  of  the  Alimentary  Canal.  By  Alfred  Ernest 
Maylard,  M.B.,  B.S.,  Senior  Surgeon  to  the  Victoria  Infirmary,  Glasgow.  With 
27  Full-Page  Plates  and  117  other  Illustrations.     Octavo.  Cloth,  $7.50 

MAYS'  Theine  in  the  Treatment  of  Neuralgia.  By  Thomas  J.  Mays,  m.d. 
i6mo.  Yz  bound,  .50 

McBEIBE.  Diseases  of  the  Throat,  Nose  and  Ear.  A  Clinical  Manual  for  Stu- 
dents and  Practitioners.  By  P.  McBride,  m.d.,  f.r.c.p.  (Edin.),  Surgeon  to  the 
Ear  and  Throat  Department  of  the  Royal  Infirmary;  Lecturer  on  Diseases  of 
Throat  and  Ear,  Edinburgh  School  of  Medicine,  etc.  With  Colored  Illustrations 
from  Original  Drawings.    2d  Edition.    Octavo.       Handsome  Cloth,  Gilt  top,  $6.00 

McNEILL.  The  Prevention  of  Epidemics  and  the  Construction  and  Man- 
agement of  Isolation  Hospitals.  By  Dr.  Roger  McNeill,  Medical  Officer  of 
Health  for  the  County  of  Argyll.  With  numerous  Plans  and  other  Illustrations. 
Octavo.  Cloth,  $3.50 

MEIGS.  Milk  Analysis  and  Infant  Feeding.  A  Treatise  on  the  Examination  of 
Human  and  Cows'  Milk,  Cream,  Condensed  Milk,  etc.,  and  Directions  as  to  the 
Diet  of  Young  Infants.     By  Arthur  V.  Meigs,  m.d.     i2mo.  Cloth,  .50 

MEMMINGER.  Diagnosis  by  the  Urine.  The  Practical  Examination  of  Urine, 
with  Special  Reference  to  Diagnosis.  By  Allard  Memminger,  m.d..  Professor 
of  Chemistry  and  of  Hygiene  in  the  Medical  College  of  the  State  of  S.  C. ;  Visiting 
Physician  in  the  City  Hospital  of  Charleston,  etc.    23  lUus.    i2mo.     Cloth,  $1.00 

MONEY.  On  Children.  Treatment  of  Disease  in  Children,  including  the  Outlines 
of  Diagnosis  and  the  Chief  Pathological  Differences  between  Children  and 
Adults.  By  Angel  Money,  m.d.,  m.r.c.p.,  Ass't  Physician  to  the  Hospital  for 
Sick  Children,  Great  Ormond  St.,  London.     2d  Edition.     i2mo.         Cloth,  $2.50 

MORRIS.  Text-Book  of  Anatomy.  791  Illustrations,  many  in  Colors.  A  com- 
plete Text-book.  Edited  by  Henry  Morris,  f.r.c.s.,  Surg,  to,  and  Lect.  on 
Anatomy  at,  Middlesex  Hospital,  assisted  by  J.  Bland  Sutton,  f.r  c.s.,  J.  H. 
Davies-Colley,  f.r.c.s.,  Wm.  J.  Walsham,  f.r.c.s.,  H.  St.  John  Brooks,  m.d., 
R.  Marcus  Gunn,  f.r.c.s.,  Arthur  Hensman,  f.r.c.s.,  Frederick  Treves, 
F.R.C.S.,  William  Anderson,  f.r.c.s.,  and  Prof.  W.  H.  A.  Jacobson.  One 
Handsome  Octavo  Volume,  with  791  Illustrations,  214  of  which  are  printed  in 
colors.  Cloth,  $6.00;  Leather,  $7. CO ;  Half  Russia,  $8.00 

"Taken  as  a  whole,  we  have  no  hesitation  in  according  very  high  praise  to  this  work.  It 
will  rank,  we  believe,  with  the  leading  Anatomies.  The  illustrations  are  handsome  and  the 
printing  is  good." — Boston  Medical  and  Surgical  Journal. 

"  The  work  as  a  whole  is  filled  with  practical  ideas,  and  the  salient  points  of  the  subject 
are  properly  emphasized.  The  surgeon  will  be  particularly  edified  by  the  section  on  the  topo- 
graphical anatomy,  which  is  full  to  repletion  of  excellent  and  useful  illustrations." — The  Medical 
Record,  N'ew  York. 

Handsome  circular,  with  sample  pagqs  and  colored  illustrations,  and  list  of 
schools  where  it  has  been  recommended,  will  be  sent  free  to  any  address. 


MEDICAL  AND  SCIENTIFIC  PUBLICATIONS.  19 

MORTON  on  Refraction  of  the  Eye.  Its  Diagnosis  and  the  Correction  of  its  Errors. 
With  Chapter  on  Keratoscopy,  and  Test  Types.  By  A.  Morton,  m.b.  Sixth 
Edition,  Revised  and  Enlarged.  Cloth,  $i.oo 

MOTTLLIN.  Surgery.  Third  Edition,  by  Hamilton.  A  Complete  Text-book. 
By  C.  W.  Mansell  Moullin,  m.a.,  m.d.  (Oxon.),  F.R.C.S.,  Surgeon  and  Lec- 
turer on  Physiology  to  the  London  Hospital ;  formerly  Radcliffe  Traveling 
Fellow  and  Fellow  of  Pembroke  College,  Oxford.  Third  American  Edition. 
Revised  and  edited  by  John  B.  Hamilton,  m.d.,  ll.d..  Professor  of  the  Principles 
of  Surgery  and  Clinical  Surgery,  Rush  Medical  College,  Chicago  ;  Professor  of 
Surgery,  Chicago  Polyclinic  ;  Surgeon,  formerly  Supervising  Surgeon-General, 
U.  S.  Marine  Hospital  Service ;  Surgeon  to  Presbyterian  Hospital ;  Consulting 
Surgeon  to  St.  Joseph's  Hospital  and  Central  Free  Dispensary,  Chicago,  etc. 
600  Illustrations,  over  200  of  which  are  original,  and  many  of  which  are  printed 
in  Colors.     Royal  Octavo.     1250  pages. 

Handsomely  bound  in  Cloth,  $6.00;  Leather,  $7.00;  Half  Russia,  $8.00 
"  The  aim  to  make  this  valuable  treatise  practical  by  giving  special  attention  to  questions  of 
treatment  has  been  admirably  carried  out.  Many  a  reader  will  consult  the  work  with  a  feeling 
of  satisfaction  that  his  wants  have  been  understood,  and  that  they  have  been  intelligently  met. 
He  will  not  look  in  vain  for  details,  without  proper  attention  to  which  he  well  knows  that  the 
highest  success  is  impossible." — The  A7nerica7t  Jou7-nal  of  Medical  Sciences. 

Handsome  circular,  with  sample  pages  and  colored  illustrations,  will  be  sent  to 
any  address  upon  application. 

Enlargement  of  the   Prostate.     Its  Treatment   and   Radical   Cure.     Illus- 
trated.    Second  Edition.     Octavo.  Preparing. 

MTJRRELL.     Massotherapeutics.     Massage  as  a  Mode  of  Treatment.     By  Wm. 
MuRRELL,  M.D.,  F.R.C.P.,  Lecturer  on  Pharmacology  and  Therapeutics  at  West- 
minster Hospital.     Sixth  Edition.    Revised.    i2mo.  Preparing. 
What  To  Do  in  Cases  of  Poisoning.     Seventh  Edition,   Enlarged  and  Re- 
vised.    64mo.                                                                                             Cloth,  $1.00 

MUTER.  Practical  and  Analytical  Chemistry.  By  John  Muter,  f.r.s.,  f.c.s., 
etc.  Fourth  Edition.  Revised,  to  meet  the  requirements  of  American  Medical 
Colleges,  by  Claude  C.  Hamilton,  m.d..  Professor  of  Analytical  Chemistry 
in  University  Med.  Col.  and  Kansas  City  Col.  of  Pharmacy.     51  lUus.    Cloth,  $1.25 

NAPHEYS'  Modern  Therapeutics.  Ninth  Revised  Edition,  Enlarged  and  Im- 
proved. In  Two  Handsome  Volumes.  Edited  by  Allen  J.  Smith,  m.d..  Pro- 
fessor of  Pathology,  University  of  Texas,  Galveston,  late  Ass't  Demonstrator  of 
Morbid  Anatomy  and  Pathological  Histology,  Lecturer  on  Urinology,  University 
of  Pennsylvania;  and  J.  Aubrey  Davis,  m.d.,  Ass't  Demonstrator  of  Obstetrics, 
University  of  Pennsylvania;  Ass't  Physician  to  Home  for  Crippled  Children,  etc. 
Vol.  L— General  Medicine  and  Diseases  of  Children. 

Handsome  Cloth  binding,  $4.00 

Vol.  II.— General  Surgery,  Obstetrics,  and  Diseases  of  Women. 

Handsome  Cloth  binding,  $4.00 

NEW  SYDENHAM  SOCIETY  Publications.  Three  to  Six  Volumes  published 
each  year.     List  of  Volumes  upon  application.  Per  annum,  $8.00 

NOTTER  and  FIRTH.  The  Theory  and  Practice  of  Hygiene.  A  Complete 
Treatise  by  J.  Lane  Notter,  m.a.,  m.d.,  f.c.s.,  Fellow  and  Member  of  Council 
of  the  Sanitary  Institute  of  Great  Britain  ;  Professor  of  Hygiene,  Army  Medical 
School;  Examiner  in  Hygiene,  University  of  Cambridge,  etc.,  and  R.  H.  Firth, 
F.R.C.S.,  Assistant  Professor  of  Hygiene,  Army  Medical  School,  Netly.  Illustrated 
by  10  Lithographic  Plates  and  135  other  Illustrations,  and  including  many  Useful 
Tables.     Octavo.     1034  pages.  Cloth,  $7.00 

*^*This  volume  is  based  upon  Parkes'  Practical  Hygiene,  which  will  not  be  pub- 
lished hereafter. 


20  P.  BLAKISTON,  SON  <5-  CO:S 

OBERSTEINER.  The  Anatomy  of  the  Central  Nervous  Org-ans.    A  Guide  to  the 

study  of  their  structure  in  Health  and  Disease.  By  Professor  H.  Obersteiner, 
of  the  University  of  \'ienna.  Translated  and  Edited  by  Alex.  Hill,  m.a.,  m.d., 
Master  of  Downing  College,  Cambridge.     iq8  Illustrations.     8vo.       Cloth,  55.50 

OETTEL.    Practical  Exercises  in  Electro-Chemistry.     By  Dr.  Felix  Oettel. 

Authorized   Translation   by    Edgar   F.  Smith,   m.a..   Professor  of  Chemistn,-, 

University  of  Pennsylvania.     Illustrated.  Cloth,  .75 

Introduction  to  Electro-Chemical  Experiments.     Illustrated.     By  same 

Author  and  Translator.  Cloth,  .75 

OHLEMANN.  Ocular  Therapeutics  for  Physicians  and  Students.  By  M.  Ohle- 
MAXX,  M.D.  Translated  and  Edited  by  Charles  A.  Oliver,  a.m.,  m.d.,  Attend- 
ing Surgeon  to  Wills  Eye  Hospital,  Ophthalmic  Surgeon  to  the  Philadelphia  and 
to  the  Presbyterian  Hospitals,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia, etc.  '  In  Press. 

ORMEROD,  Diseases  of  Nervous  System,  Student's  Guide  to.  By  J,  A.  Ormerod, 
M.D.  (O.xon.),  f.r.c.p.  (Lond.),  :\Iem.  Path.,  Clin.,  Ophth.,  and  Neurol.  Societies, 
Phvsician  to  National  Hospital  for  Paralyzed  and  Epileptic  and  to  City  of  London 
Hospital  for  Diseases  of  the  Chest,  Dem.  of  Morbid  Anatomy,  St.  Bartholo- 
mew's Hospital,  etc.     With  66  Wood  Engravings.     i2mo.  Cloth,  gi.oo 

OSGOOD.    The  "Winter  and  Its  Dangers.    By  Hamilton  Osgood,  m.d.  Cloth,  .40 

OSLER.    Cerebral  Palsies  of  Children.    A  Clinical  Study.    By  William  Osler, 

M.D.,  F.R.C.P.  (Lond.),  Professor  of  Medicine,  Johns    Hopkins  University,  etc. 

8vo.  Cloth,  $2.00 

Chorea  and  Choreiform  Affections.    8vo.  Cloth,  32.00 

OSTROM.  Massage  and  the  Original  Swedish  Movements.  Their  AppHcation 
to  Various  Diseases  of  the  Body.  A  Manual  for  Students,  Nurses  and  Physicians. 
By  KuRRE  W.  OsTROM,  from  the  Royal  University  of  Upsala,  Sweden;  Instructor 
in  Massage  and  Swedish  Movements  in  the  Hospital  of  the  University  of 
Pennsylvania,  and  in  the  Philadelphia  Polyclinic  and  College  for  Graduates  in 
Medicine,  etc.  Third  Edition.  Enlarged.  Illustrated  by  94  Wood  Engrav- 
ings, many  of  which  were  drawn  especially  for  this  purpose.    i2mo.     Cloth,  gi.oo 

PACKARD'S  Sea  Air  and  Sea  Bathing-.    By  John  H.  Packard,  m.d.      Cloth,  .40 

PARKES'  Practical  Hygiene.  By  Edward  A.  Parkes,  m.d.  Superseded  by 
"  Notter  and  Firth  "  Treatise  on  Hygiene.     See  previous  page. 

PARKES.  Hygiene  and  Public  Health.  A  Practical  Manual.  By  Louis  C. 
Parkes,  m.d.,  d.p.h.  Lond.  Univ.,  Lect.  on  Public  Health  at  St.  George's  Hos- 
pital, Medical  Officer  of  Health,  Parish  of  Chelsea,  London,  etc.  Fifth  Edition, 
Enlarged  and  Revised.     80  Illustrations.     i2mo.  Cloth,  $2.50 

The    Elements    of    Health.       An    Introduction    to   the   Study    of   Hygiene. 
Illustrated.  Cloth,  $1.25 

PARRISH'S  Alcoholic  Inebriety.  From  a  ^Medical  Standpoint,  with  Illustrative 
Cases  from  the  Clinical  Records  of  the  Author.  By  Joseph  Parrish,  m.d., 
President  of  the  Amer.  Assoc,  for  Cure  of  Inebriates.  Cloth,  31.00 

PEREIRA'S  Prescription  Book.  Containing  Lists  of  Terms,  Phrases,  Contrac- 
tions and  Abbreviations  used  in  Prescriptions,  Explanatorj^  Notes,  Grammatical 
Construction  of  Prescriptions,  Rules  for  the  Pronunciation  of  Pharmaceutical 
Terms.    By  Jonathan  Pereira,  m.d.    Sixteenth  Edition.    Cloth,  .75;  Tucks  gi. 00 

PHILLIPS.  Spectacles  and  Eyeglasses,  Their  Prescription  and  Adjustment.  By 
R.  J.  Phillips,  m.d.,  Instructor  on  Diseases  of  the  Eye,  Philadelphia  PolycHnic, 
Ophthalmic  Surgeon,  Presbyterian  Hospital.  Second  Edition,  Revised  and 
Enlarged.     49  Illustrations.     i2mo.  Cloth,  |i.oo 


MEDICAL  AND  SCIENTIFIC  PUBLIC  A  TIONS.  21 

PHYSICIAN'S  VISITING  LIST.  Published  Annually.  Forty-seventh  Year  (1898) 
of  its  Pubhcation. 

Hereafter  all  styles  will  contain  the  interleaf  or  special  memoranda  page,  except 
the  Monthly  Edition,  and  the  sizes  for  75  and  ico  Patients  will  come  in  two  volumes 
only.     The  Sale  of  this  Visiting  List  increased  over  ten  per  cent,  in  1896. 

KEGULAK  EDITION. 
For  25  Patients  weekly.  Tucks,  pocket  and  pencil,  Gilt  Edges,  $1.00 

50         "  "  "  "  ' 1.25 

<<  <<  ^      1  f  Jan.  to  June  ]  ,,  ,,  ,,         ,,         ,, 

50  '2  vols.  IJ^iytoDecj  ^-"^ 

«,-         <(  <<  ^      1  ( Jan.  to  June  I  ,,  ,.  ,,         ,,         ,, 

75  "2  vols.  |juiytoi)ec.}  2-°° 

T^^         i<  <<  ^      1  f  Jan.  to  Tune)  ,,  ,,  .,         ,, 

"2  vols.  {July  to  Dec.  I  '-"5 

Perpetual  Edition,  without  Dates  and  with  Special    Memorandum    Pages. 

For  25  Patients,  interleaved,  tucks,  pocket  and  pencil,  ....         $1.25 

50         "  "  "  «  .<  «  ....  1.50 

Monthly  Edition,  without  Dates.    Can  be  commenced  at  any  time  and  used 

until  full.    Requires  only  one  writing  of  patient's  name  for  the  whole  month. 

Plain  binding,  without  Flap  or  Pencil,  .75.      Leather  cover,  Pocket  and  Pencil,  $1.00 

EXTRA  Pencils  will  be  sent,  postpaid,  for  25  cents  per  half  dozen. 

f®"  This  List  combines  the  several  essential  qualities  of  strength,  compactness, 

durability  and  convenience.    It  is  made  in  all  sizes  and  styles  to  meet  the  wants  of  all 

physicians.     It  is  not  an  elaborate,  complicated  system  of  keeping  accounts,  but  a 

plain,  simple  record,  that  may  be  kept  with  the  least  expenditure  of  time  and  trouble — 

hence  its  popularity.    A  special  circular,  descriptive  of  contents  will  be  sent  upon 

application. 

POTTER.  A  Handbook  of  Materia  Medica,  Pharmacy,  and  Therapeutics,  in- 
cluding the  Action  of  Medicines,  Special  Therapeutics  of  Disease,  Official  and 
Practical  Pharmacy,  and  Minute  Directions  for  Prescription  Writing,  etc.  In- 
cluding over  600  Prescriptions  and  Formulce.  By  Samuel  O.  L.  Potter,  m.a., 
M.D.,  M.R.c.P.  (Lond.),  Professor  of  the  Principles  and  Practice  of  Medicine  and 
Chnical  Medicine  in  the  College  of  Physicians  and  Surgeons,  San  Francisco ; 
late  A.  A.  Surgeon  U.  S.  Army.  Sixth  Edition,  Revised  and  Enlarged  by  100 
Pages.    Svo.     With  Thumb  Index  in  each  copy. 

Cloth,  $4-5° ;  Leather,  $5.50;  Half  Russia  $6.50 
Compend  of  Anatomy,  including  Visceral  Anatomy.    Fifth  Edition.    Re- 
vised, and  greatly  Enlarged.     With  16  Lithographed  Plates  and  117  other 
Illustrations.     Being  No.  i  f  Quiz-  Compend  ?  Series. 

Cloth,  .80;  Interleaved  for  taking  Notes,  $1.25 
Compend  of  Materia  Medica,  Therapeutics  and  Prescription  Writing-, 
with  special  reference  to  the  Physiological  Action  of  Drugs.  Sixth  Revised 
and  Improved  Edition,  with  Index,  based  upon  U.  S.  P.  1890.  Being-  No. 
6  ?  Quiz-Compend?  Series.  Cloth,  .80.  Interleaved  for  taking  Notes,  $1.25 
Speech  and  Its  Defects.  Considered  Physiologically,  Pathologically  and 
Remedially;  being  the  Lea  Prize  Thesis  of  Jefferson  Medical  College,  1882. 
Revised  and  Corrected.     i2mo.  Cloth,  ^i.oo 

POWELL.    Diseases  of  the  Lungs  and  Pleurse,  Including  Consumption.    By 

R.  Douglas  Powell,  m.d.,  f.r.c.p.,  Physician  to  the  Middlesex  Hospital,  and 
Consulting  Physician  to  the  Hospital  for  Consumption  and  Diseases  of  the  Chest 
at  Brompton.  Fourth  Edition.  With  Colored  Plates  and  Wood  Engravings. 
8vo.  Cloth,  14.00 

POWER.  Surgical  Diseases  of  Children  and  their  Treatment  by  Modern 
Methods.  By  D'Arcy  Power,  m.a.,  f.r.c.s.  (Eng.),  Demonstrator  of  Operative 
Surgery,  St.  Bartholomew's  Hospital ;  Surgeon  to  the  Victoria  Hospital  for 
Children.     Illustrated.     i2mo.  Cloth,  $2.50 


22  P.  BLAKISTON,  SON  &*  CO:S 

PRESTON.    Hysteria  and  Certain  Allied  Conditions.    Their  Nature  and  Treat- 
ment.    With  special  reference   to  the  appHcation   of   the  Rest  Cure,    Massage, 
Electro-therapy,   Hypnotism,    etc.     By  George  J.  Preston,  m.d.,  Professor  of 
Diseases  of  the  Nervous  System,  College  of  Physicians  and  Surgeons,  Balti- 
more ;  Visiting  Physician  to  the  City  Hospital ;  Consulting  Neurologist  to  Bay 
View  Asylum  and  the  Hebrew  Hospital ;  Member  American  Neurological  Asso- 
ciation, etc.     With  Illustrations.     i2mo.  Cloth,  $2.00 
Synopsis  of  Contents. — Historical.     The  Nature  of  Hysteria ;    Etiology  and 
Pathology.     Symptomatology.     Disturbances  of  Motion  :  Tremor,  Contracture,  Par- 
alysis.    Convulsive  Attacks  :  Major  and   Minor  Attacks.      Hystero-Epilepsy.      The 
Mental  Condition  in  Hysteria.     Visceral  and  Vasomotor  Disturbances.     Diagnosis. 
Treatment :  Electro-Therapy,  The  Rest  Cure,  Hypnotism,  Surgical  Interference  in 
the  Treatment  of  Hysteria. 

PRITCHAED.  Handbook  of  Diseases  of  the  Ear.  By  Urban  Pritchard, 
M.D.,  F.R.C.S.,  Professor  of  Aural  Surgery,  King's  College,  London,  Aural  Sur- 
geon to  King's  College  Hospital,  Senior  Surgeon  to  the  Royal  Ear  Hospital,  etc. 
Third  Edition,  Enlarged.    Many  Illustrations  and  Formulas.     i2mo.    Cloth,  $1.50 

PROCTOR'S  Practical  Pharmacy.  Lectures  on  Practical  Pharmacy.  With  Wood 
Engravings  and  32  Lithographic  Fac -simile  Prescriptions.  By  Barnard  S. 
Proctor.  Third  Edition.  Revised  and  with  elaborate  Tables  of  Chemical 
Solubilities,  etc.  Cloth,  $3.00 

REESE'S  Medical  Jurisprudence  and  Toxicology.  A  Text-book  for  Medical  and 
Legal  Practitioners  and  Students.  By  John  J.  Reese,  m.d..  Editor  of  Taylor's 
Jurisprudence,  Professor  of  the  Principles  and  Practice  of  Medical  Jurisprudence, 
including  Toxicology,  in  the  University  of  Pennsylvania  Medical  Department. 
Fifth  Edition.  Revised  and  Edited  by  Henry  Leffmann,  m.d.,  Pathological 
Chemist,  Jefferson  Medical  College  Hospital ;  Chemist,  State  Board  of  Health  ; 
Professor  of  Chemistry,  Woman's  Medical  College  of  Penna.,  etc.  i2mo.  645 
pages.  Cloth,  $3.00;   Leather,  $3.50 

"  To  the  student  of  medical  jurisprudence  and  toxicology  it  is  invaluable,  as  it  is  concise, 

clear,  and  thorough  in  every  respect." — The  Atnericatt  Journal  of  the  Medical  Sciences. 

REEVES.  Medical  Microscopy.  Illustrated.  A  Handbook  for  Physicians  and 
Students,  including  Chapters  on  Bacteriology,  Neoplasms,  Urinary  Examination, 
etc.  By  James  E.  Reeves,  m.d.,  Ex-President  American  Public  Health  Associa- 
tion, Member  Association  American  Physicians,  etc.  Numerous  Illustrations, 
some  of  which  are  printed  in  colors.  i2mo.     Handsome  Cloth,  $2.50 

REEVES.  Bodily  Deformities  and  their  Treatment.  A  Handbook  of  Practical 
Orthopaedics.  By  H.  A.  Reeves,  m.d..  Senior  Ass't  Surgeon  to  the  London  Hos- 
pital, Surgeon  to  the  Royal  Orthopaedic  Hospital.     228  Illustrations.     Cloth,  $1.75 

REGIS.  Mental  Medicine.  A  Practical  Manual.  By  Dr.  E.  Regis,  formerly 
Chief  of  Clinique  of  Mental  Diseases,  Faculty  of  Medicine  of  Paris  ;  Physician 
of  the  Maison  de  Sante  de  Castel  d'Andorte  ;  Professor  of  Mental  Diseases, 
Faculty  of  Medicine,  Bordeaux,  etc.  With  a  Preface  by  M.  Benjamin  Ball, 
Clinical  Professor  of  Mental  Diseases,  Faculty  of  Medicine,  Paris.  Authorized 
Translation  from  the  Second  Edition  by  H.  M.  Bannister,  m.d.,  late  Senior 
Assistant  Physician,  Illinois  Eastern  Hospital  for  the  Insane,  etc.  With  an  In- 
troduction by  the  Author.     i2mo.     692  pages.  Cloth,  $2.00 

RICHARDSON.  Long-  Life,  and  How  to  Reach  It.  By  J.  G.  Richardson,  Prof, 
of  Hygiene,  University  of  Pennsylvania.  Cloth,  .40 

RICHARDSON'S  Mechanical  Dentistry.  A  Practical  Treatise  on  Mechanical 
Dentistry.  By  Joseph  Richardson,  d.d.s.  Seventh  Edition.  Thoroughly 
Revised  and  in  many  parts  Rewritten  by  Dr.  Geo.  W.  Warren,  Chief  of  the 
Clinical  Staff,  Pennsylvania  College  of  Dental  Surgery,  Philadelphia.  With  691 
Illustrations,  many  of  which  are  from  original  Wood  Engravings.  Octavo. 
675  pages.  Cloth,  $5.00;  Leather,  $6.00 ;  Half  Russia,  $7.00 


MEDICAL  AND  SCIENTIFIC  PUBLICATIONS. 23 

RICHTER'S  Inorganic  Chemistry.     A  Text-book  for  Students.     By  Prof.  \^ICT0R 

vox   RiCHTER,    Universit)'  of  Breslau.     Fourth  American,  from  Sixth  German 

Edition.      Authorized   Translation   by  Edgar  F.  Smith,  m.a.,  ph.d.,  Prof,  of 

Chemistr}-,  University  of  Pennsylvania,  Member  of  the  Chemical  Societies  of 

Berlin  and  Paris.    89  Illustrations  and  a  Colored  Plate.     l2mo.  Cloth,  51.75 

Organic   Chemistry.      The   Chemistry'  of  the    Carbon    Compounds.      Third 

American  Edition,  translated  from  the  Last  German  by  Edgar  F.  Smith, 

M.A.,  PH.D.,  Professor  of  Chemistry,  University  of  Pennsylvania.    Illustrated. 

I2mo.  '  '  Frepari7ig. 

ROBERTS.  Practice  of  Medicine.  The  Theorv-  and  Practice  of  IVIedicine.  By 
Frederick  Roberts,  m.d..  Professor  of  Therapeutics  at  University  College, 
London.    Ninth  Edition,  with  Illustrations.    8vo.         Cloth,  $4.50  ;  Leather,  §5.50 

ROBERTS.  Eractures  of  the  Radius,  A  Clinical,  Pathological,  and  Experimental 
Study.  By  JoHX  B.  Roberts,  m.d.,  Professor  of  Anatomy  and  Surger\'  in  the 
Philadelphia  Polychnic,  etc.     33  Illustrations.     Svo.  Cloth,  Si.co 

ROBINSON.  Latin  Grammar  of  Pharmacy  and  Medicine.  By  D.  H.  Robixson, 
PH.D.,  Professor  of  Latin  Language  and  Literature,  University  of  Kansas.  Intro- 
duction by  L.  E.  Sayre,  ph.g.,  Professor  of  Pharmacy  in,  and  Dean  of  the  Dept. 
of  Pharmacy,  University  of  Kansas.  Third  Edition.  Revised  with  the  help 
of  Prof.  L.  E.  Sayre,  of'University  of  Kansas,  and  Dr.  Charles  Rice,  of  the 
College  of  Pharmacy  of  the  city  of  New  York.      i2mo.  Cloth,  S1.75 

ST.  CLAIR.  Medical  Latin.  Designed  expressly  for  the  Elementary  Training 
of  Medical  Students.  By  \V.  T.  St.  Clair,  Instructor  in  Latin  in  the  Kentucky 
School  of  ^ledicine  and  in  the  Louisville  ^lale  High  School.    i2mo.    Cloth,  Si. 00 

SANSOM.  Diseases  of  The  Heart.  The  Diagnosis  and  Pathology  of  Diseases  of 
the  Heart  and  Thoracic  Aorta.  By  A.  Erxest  Saxsom,  m.d.,  f.r.C.P.,  Physician 
to  the  London  Hospital,  etc.     With  Illustrations.     Svo.  Cloth,  56.00 

SAYRE.  Organic  Materia  Medica  and  Pharmacognosy,  An  Introduction 
to  the  Study  of  the  \'egetable  Kmgdom  and  the  \'egetable  and  Animal  Drugs. 
Comprising  the  Botanical  and  Physical  Characteristics,  Source,  Constituents,  and 
PharmacopcEial  Preparations.  With  Chapters  on  Synthetic  Organic  Remedies, 
Insects  Injurious  to  Drugs,  and  Pharmacal  Botany.  By  L.  E.  Sayre,  ph.g.. 
Professor  of  Pharmacy  and  r^Iateria  ^ledica  in  the  University  of  Kansas,  Mem- 
ber of  the  Committee  of  Revision  of  the  U.  S.  Pharmacopoeia,  1890.  A  Glossary 
and  543  Illustrations.     Svo.  Cloth,  S4.00  ;  Sheep,  55.00;  Half  Russia,  56.00 

SCHAMBERG.  Compend  of  Diseases  of  the  Skin.  By  Jay  F.  Schamberg, 
Instructor  in  Skin  Diseases,  Philadelphia  Polychnic  ;  Quiz-Master  at  University 
of  Pennsylvania.     Illustrated.  Cloth,  .80.     Interleaved,  51.25 

SCHREINER.  Diet  List.  Arranged  in  the  Form  of  a  Chart  on  which  Articles  of 
Diet  can  be  indicated  for  any  Disease.  By  E.  R.  Schreiner,  m.d.,  Ass't  Dem. 
of  Physiology,  University  of  Penna.  Put  up  in  Pads  of  50  with  General  Dietetic 
Directions  on  Wrapper.  '  Per  Pad,     .75 

SCHTJLTZE,  Obstetrical  Diagrams.  Being  a  Series  of  20  Colored  Lithograph 
Charts,  imperial  map  size,  of  Pregnancy  and  ^lidwifery,  with  accompanying 
explanatory  (German)  text,  illustrated  by  wood-cuts.  By  Dr.  B.  S.  Schultze, 
Professor  of  Obstetrics,  University  of  Jena.     Second  Revised  Edition. 

Price,  in  Sheets,  S26.00 ;  Mounted  on  Rollers,  Muslin  Backs,  S36.00 

SCOVILLE.  The  Art  of  Compounding.  A  Text-book  for  Students  and  a  Refer- 
ence Book  for  Pharmacists.  By  Wilbur  L.  Scoville,  ph.g..  Professor  of  Ap- 
plied Pharmacy  and  Director  of  the  Pharmaceutical  Laboraton,-  in  the  ^^lassa- 
chusetts  College  of  Pharmacy.     Second  Edition,  Enlarged  and  Improved. 

Cloth,  52.50;  Sheep,  53.50;   Half  Russia,  54.50 

SEWELL.  Dental  Surgery,  including  Special  Anatomy  and  Surgery.  By  Henry 
Sewell,  M.R.C.S.,  L.D.S.,  President  Odontological  Society  of  Great  Britain.  3d 
Edition,  greatly  enlarged,  with  about  200  Illustrations.  Cloth,  52.00 

SHAWE.  Notes  for  Visiting  Nurses,  and  all  those  interested  in  the  working  and 
organization  of  District,  \"isiting,  or  Parochial  Nurse  Societies.  By  Rosalixd 
Gillette  Shawe,  District  Nurse  for  the  Brooklyn  Red  Cross  Society.  With  an 
Appendix  explaining  the  organization  and  working  of  various  A'isiting  and  Dis- 
trict Nurse  Societies,  by  Helex  C.  Jexks,  of  Philadelphia.    i2mo.    Cloth,  51.00 


24  P.  BLAKISTON,  SON  &-  CO.'S 

SMITH.  Abdominal  Surgery.  Being  a  Systematic  Description  of  all  the  Princi- 
pal Operations.  By  J.  Greig  Smith,  m.a.,  f.r.s.e.,  Surg,  to  British  Royal  In- 
firmary. 224  Illustrations.  Sixth  Edition,  Enlarged  and  Thoroughly  Revised 
by  James  Swain,  m.d.  (Lond.),  f.r.c.s..  Professor  of  Surgery,  University  College, 
Bristol,  etc.     2  Volumes.     Octavo.  Cloth,  $10.00 

SMITH.  Electro-Chemical  Analysis.  By  Edgar  F.  Smith,  Professor  of  Chem- 
istry, University  of  Pennsylvania.  Second  Edition,  Revised  and  Enlarged.  27 
Illustrations.     i2mo.  Cloth,  $1.25 

*^*  See  also  Oettel  and  Richter. 

SMITH  AND  KELLER.  Experiments.  Arranged  for  Students  in  General  Chem- 
istry. By  Edgar  F.  Smith,  Professor  of  Chemistry,  University  of  Pennsylvania, 
and  Dr.  H.  F.  Keller,  Professor  of  Chemistry,  Philadelphia  High  School.  Third 
Edition.     8vo.     Illustrated.  Cloth,  .60 

STAMMER.  Chemical  Problems,  with  Explanations  and  Answers.  By  Karl 
Stammer.  Translated  from  the  Second  German  Edition,  by  Prof.  W.  S.  Hos- 
KINSON,  a.m.,  Wittenberg  College,  Springfield,  Ohio.     i2mo.  Cloth.  .50 

STARLING.  Elements  of  Human  Physiolog-y.  By  Ernest  H.  Starling,  m.d. 
Lond.,  m.r.c.p.,  Joint  Lecturer  on  Physiology  at  Guy's  Hospital,  London, 
etc.     With  100  Illustrations.      i2mo.     437  pages.  Cloth,  $1.00 

STARR.  The  Digestive  Organs  in  Childhood.  Second  Edition.  The  Diseases 
of  the  Digestive  Organs  in  Infancy  and  Childhood.  With  Chapters  on  the 
Investigation  of  Disease  and  the  Management  of  Children.  By  Louis  Starr, 
M.D.,  late  Clinical  Prof,  of  Diseases  of  Children  in  the  Hospital  of  the  University 
of  Penn'a;  Physician  to  the  Children's  Hospital,  Phila.  Second  Edition. 
Revised  and  Enlarged.  Illustrated  by  two  Colored  Lithograph  Plates  and 
numerous  Wood  Engravings.     Crown  Octavo.  Cloth,  $2.00 

The  Hygiene  of  the  Nursery,  including  the  General  Regimen  and  Feed- 
ing of  Infants  and  Children,  and  the  Domestic  Management  of  the  Ordinary 
Emergencies  of  Early  Life,  Massage,  etc.  Sixth  Edition.  Enlarged.  25 
Illustrations.     i2mo.     280  pages.  Cloth,  $1.00 

STEARNS.  Lectures  on  Mental  Diseases.  By  Henry  Putnam  Stearns,  m.d., 
Physician  Superintendent  at  the  Hartford  Retreat,  Lecturer  on  Mental  Diseases 
in  Yale  University,  Member  of  the  American  Medico-Psychological  Ass'n,  Hon- 
orary Member  of  the  British  Medico- Pyschological  Society.  With  a  Digest  of 
Laws  of  the  Various  States  Relating  to  Care  of  Insane.    Illustrated. 

Cloth,  $2.75;  Sheep,  $3.25 

STEVENSON  AND  MURPHY.    A  Treatise  on  Hygiene.    By  Various  Authors. 
Edited  by  Thomas  Stevenson,  m.d.,  f.r.c.p..  Lecturer  on  Chemistry  and  Medi- 
cal Jurisprudence  at  Guy's    Hospital,  London,  etc.,  and  Shirley  F.  Murphy, 
Medical  Officer  of  Health  to  the  County  of  London.    In  Three  Octavo  Volumes. 
Vol.  I.    With  Plates  and  Wood  Engravings.    Octavo.  Cloth,  $6.00 

Vol.  11.     With  Plates  and  Wood  Engravings.     Octavo.  Cloth,  $6.00 

Vol.  III.     Sanitary  Law.     Octavo.  Cloth,  $5.00 

***  Special  Circular  up07i  application. 

STEWART'S  Compend  of  Pharmacy.  Based  upon  "Remington's  Text-Book  of 
Pharmacy."  By  F.  E.  Stewart,  m.d.,  ph. g.,  Quiz-Master  in  Chem.  and  Theoreti- 
cal Pharmacy,  Phila.  College  of  Pharmacy;  Lect.  in  Pharmacology,  Jefferson 
Medical  College.  Fifth  Ed.  Revised  in  accordance  with  U.  S.  P.,  1890.  Com- 
plete tables  of  Metric  and  English  Weights  and  Measures,  f  Quiz- Compend  f 
Series.  Cloth,  .80;  Interleaved  for  the  addition  of  notes,  $1.25 

STIRLING.  Outlines  of  Practical  Physiology.  Including  Chemical  and  Experi- 
mental Physiology,  with  Special  Reference  to  Practical  Medicine.  By  W.  Stir- 
ling, m.d.,  Sc.d.,  Professor  of  Physiology  and  Histology,  Owens  College,  Victoria 
University,  Manchester.  Examiner  in  Physiology,  Universities  of  Edinburgh 
and  London.     Third  Edition.     289  Illustrations.  Cloth,  $2.00 

Outlines  of  Practical  Histology.  368  Illustrations.  Second  Edition.  Re- 
vised and  Enlarged  with  new  Illustrations.     i2mo.  Cloth,  $2.00 


MEDICAL  AND  SCIENTIFIC  PUBLIC  A  TIONS.  25 

STOHR.    Text-Book  of  Histology,  Including  the  Microscopical  Technique. 

By  Ur.  Philipp  Stohr,  University  of  Zurich.  Authorized  Translation  by 
Emma  L.  Billstein,  m.d.,  Demonstrator  of  Histology  and  Embryology, 
Woman's  Medical  College  of  Pennsylvania.  Edited,  with  Additions,  by  Dr. 
Alfred  Schaper,  Demonstrator  of  Histology  and  Embryology,  Harvard 
Medical  School,  Boston.     268  Illustrations.     Octavo.  Cloth,  $3.00 

STRAHAN.  Extra-Uterine  Pregnancy.  The  Diagnosis  and  Treatment  of  Extra- 
Uterine  Pregnancy.  Being  the  Jenks  Prize  Essay  of  the  College  of  Physicians 
of  Philadelphia.  By  John  Strahan,  m.d.  (Univ.  of  Ireland),  late  Res.  Surgeon 
Belfast  Union  Infirmary  and  Fever  Hospital.     Octavo.  Cloth,  .75 

SUTTON'S  Volumetric  Analysis.  A  Systematic  Handbook  for  the  Quantitative 
Estimation  of  Chemical  Substances  by  Measure,  Applied  to  Liquids,  Solids  and 
Gases.  Adapted  to  the  Requirements  of  Pure  Chemical  Research,  Pathological 
Chemistry,  Pharmacy,  Metallurgy,  Photography,  etc.,  and  for  the  Valuation  of 
Substances  Used  in  Commerce,  Agriculture,  and  the  Arts.  By  Francis  Sutton, 
F.c.s.     Seventh  Edition,  Revised  and  Enlarged,  with  112  Illustrations.     8vo. 

Cloth,  $4.50 

SWAIN.  Surgical  Emergencies,  together  with  the  Emergencies  Attendant  on 
Parturition  and  the  Treatment  of  Poisoning.  A  Manual  for  the  Use  of  Student, 
Practitioner,  and  Head  Nurse.  By  William  Paul  Swain,  f.r.c.s.,  Surgeon  to 
the  South  Devon  and  East  Cornwall  Hospital,  England.  Fifth  Edition.  i2mo. 
149  Illustrations.  Cloth,  $1.75 

SWANZY.    Diseases  of  the  Eye  and  their  Treatment.    A  Handbook  for  Physi- 
cians and  Students.     By  Henry  R.  Swanzy,  a.m.,  m.b.,  f.r.c.s.i..  Surgeon  to 
the  National  Eye  and  Ear  Infirmary  ;  Ophthalmic  Surgeon  to  the  Adelaide  Hos- 
pital, Dublin.     Sixth    Edition,  Thoroughly  Revised  and  Enlarged.     158  Illus- 
trations, one  Plain  Plate,  and  a  Zephyr  Test  Card.     i2mo.  Cloth,  ^3.00 
"  Is  without  doubt  the  most  satisfactory  manual  we  have  upon  diseases  of  the  eye.     It  occu- 
pies the  middle  ground  between  the  students'  manuals,  which  are  too  brief  and  concise,  and  the 
encyclopedic  treatises,  which  are  too  extended  and  detailed  to  be  of  special  use  to  the  general 
practitioner." — Chicago  Medical  Recorder. 

SYMONLS.  Manual  of  Chemistry,  for  Medical  Students.  By  Brandreth 
Symonds,  a.m.,  m.d.,  Ass't  Physician  Roosevelt  Hospital,  Out- Patient  Department ; 
Attending  Physician  Northwestern  Dispensary,  New  York.  Second  Edition. 
i2mo.  Cloth,  $2.00 

TAFT'S  Operative  Dentistry.     A  Practical  Treatise  on  Operative  Dentistry.     By 
Jonathan  Taft,  d.d.s.     Fifth  Revised  and  Enlarged  Edition.     Over  100  Illus- 
trations.    Svo.  Preparing. 
Index  of  Dental  Periodical  Literature.    8vo.                           Cloth,  $2.00 

TALBOT.  Irregularities  of  the  Teeth,  and  Their  Treatment.  By  Eugene  S. 
Talbot,  m.d.,  Professor  of  Dental  Surgery  Woman's  Medical  College,  and 
Lecturer  on  Dental  Pathology  in  Rush  Medical  College,  Chicago.  Second  Edi- 
tion, Revised  and  Enlarged  by  about  100  pages.  Octavo.  234  Illustrations 
(169  of  which  are  original).     261  pages.  Cloth,  $3.00 

TANNER'S  Memoranda  of  Poisons  and  their  Antidotes  and  Tests.  By  Thos. 
Hawkes  Tanner,  m.d.,  f.r.c.p.  7th  American,  from  the  Last  London  Edition. 
Revised  by  John  J.  Reese,  m.d..  Professor  Medical  Jurisprudence  and  Toxi- 
cology in  the  University  of  Pennsylvania.     i2mo.  Cloth,  .75 

TAYLOR.  Practice  of  Medicine.  A  Manual.  By  Frederick  Taylor,  m.d., 
Physician  to,  and  Lecturer  on  Medicine  at,  Guy's  Hospital,  London  ;  Physician  to 
Evelina  Hospital  for  Sick  Children,  and  Examiner  in  Materia  Medica  and  Phar- 
maceutical Chemistry,  University  of  London.  Cloth,  $2.00;  Sheep,  $2.50 


26  P.  B  LA  K IS  TON,  SON  &-  CO.'S 


TAYLOR  AND  WELLS.  Diseases  of  Children.  A  Manual  for  Students  and 
Physicians.  By  John  Madison  Taylor,  a.b.,  m.d.,  Professor  of  Diseases  of 
Children,  Philadelphia  Polyclinic;  Assistant  Physician  to  the  Children's  Hospi- 
tal and  to  the  Orthopedic  Hospital;  Consulting  Physician  to  the  Elwyn  and  the 
Vineland  Training  Schools  for  Feeble-Minded  Children  ;  Neurologist  to  the 
Howard  Hospital,  etc. ;  and  William  H.  Wells,  m.d.,  Adjunct-Professor  of 
Obstetrics  and  Diseases  of  Infancy  in  the  Philadelphia  Polyclinic ;  late  Assistant 
Demonstrator  of  Clinical  Obstetrics  and  Diseases  of  Infancy  in  Jefferson  Medi- 
cal College.     With  Illustrations.  /n  Press. 

Proposed  Contents  and  Arrangement. — I.  Clinical  Investigation.  II  and 
III.  Hygiene  and  Diet.  IV.  Care  of  Children  of  Feeble  Resistance,  including  Sys- 
tematic Developmental  Methods.  V.  Diseases  Occurring  At  or  Near  Birth.  VI. 
Acute  Infectious  Diseases.  VII.  General  Diseases,  Tuberculosis,  Syphilis,  Malaria, 
Rachitis,  Rheumatism,  etc.  VIII.  Diseases  of  Digestive  Organs,  including  Parasites. 
IX.  Diseases  of  the  Liver,  Cecum,  and  Appendix.  X.  Diseases  of  the  Peritoneum, 
Intestinal  Malformations  and  Obstructions.  XI.  Diseases  of  the  Respiratory  Organs. 
XII.  Diseases  of  the  Heart.  XIII.  Diseases  of  the  Blood  and  Blood-making  Organs. 
XIV.  Nervous  Diseases  (including  Diabetes).  XV.  Diseases  of  the  Nose,  Pharynx, 
and  Naso-Pharynx.  XVI.  Genito-Urinary  Diseases.  XVII.  Diseases  of  Degeneracy, 
Thyroid  Thymus  Glands,  Dwarfs  and  Dwarfing,  Cretins,  Leprosy,  Idiocy,  Feeble- 
mindedness, and  Insanity,  etc.  XVIII.  Diseases  of  the  Skin.  XIX.  Injuries  and 
Shock.  XX.  Emergencies — Medical  and  Surgical.  XXI.  Diseases  of  the  Bones  and 
Joints.     XXII.  Curvatures  of  the  Spine.     XXIII.  Pott's  Disease.     XXIV.  Tumors. 

TEMPERATURE  Charts  for  Recording  Temperature,  Respiration,  Pulse,  Day  of 
Disease,  Date,  Age,  Sex,  Occupation,  Name,  etc.  Put  up  in  pads;  each  .50 

THOMPSON.  Urinary  Organs.  Diseases  of  the  Urinary  Organs.  Containing  32 
Lectures.  By  Sir  Henry  Thompson,  f.r.c.s..  Emeritus  Professor  of  Clinical  Sur- 
gery in  University  College.  Eighth  London  Edition.  121  Illustrations.  Octavo. 
470  pages.  Cloth,  $3.00 

THORINGTON.  RetinOSCOpy  (The  Shadow  Test)  in  the  Determination  of 
Refraction  at  One  Metre  Distance  with  the  Plane  Mirror.  By  James  Thoring- 
ton,  m.d..  Adjunct  Professor  of  Diseases  of  the  Eye  in  the  Philadelphia  Poly- 
clinic ;  Ophthalmologist  to  the  Vineland  Training  School  and  to  the  M.  E. 
Orphanage ;  Lecturer  on  the  Anatomy,  Physiology,  and  Care  of  the  Eyes  in  the 
Philadelphia  Manual  Training  Schools,  etc.  With  38  Illustrations,  several  of 
which  are  Colored.     Second  Edition,  Enlarged.     i2mo.  Cloth,  $1.00 

TOMES'  Dental  Anatomy.    A  Manual  of  Dental  Anatomy,  Human  and  Compara- 
tive.    By  C.  S.  Tomes,  d.d.s.     235  Illustrations.     4lh  Ed.     i2mo.     Cloth,  ^3.50 
Dental   Surgery.     A  System   of   Dental  Surgery,     By  John   Tomes,  f.r.s. 
Fourth   Edition,  Thoroughly  Revised.      By  C.  S.  Tomes,  d.d.s.     With  289 
Illustrations.     i2mo.     717  pages.  Cloth,  $4.00 

TREVES.  German-English  Medical  Dictionary.    By  Frederick  Treves,  f.r.c.s., 

assisted  by  Dr.  Hugo  Lang,  b.a.  (Munich).     i2nio.  ^  Russia,  $3.25 

Physical  Education,  Its  Effects,  Value,  Methods,  etc.  Cloth,  .75 

TUKE.  Dictionary  of  Psychological  Medicine.  Giving  the  Definition,  Ety- 
mology, and  Synonyms  of  the  Terms  used  m  Medical  Psychology,  with  the 
Symptoms,  Pathology,  and  Treatment  of  the  recognized  forms  of  Mental  Dis- 
orders, together  with  the  Law  of  Lunacy  in  Great  Britain  and  Ireland.  Edited  by 
D.  Hack  Tuke,  m.d.,ll.d..  Examiner  in  Mental  Physiology  in  the  University 
of  London.     Two  Volumes.     Octavo.     1477  pages.  Cloth,  $10.00 

"This  is  an  elaborate  and  valuable  contribution  to  the  literature  of  medical  psychology,  and 
will  be  found  a  valuable  work  of  reference.  ...  A  comprehensive  standard  book." — 7/ie 
British  Medical  Jour7iaL 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  27 

TTJRNBULL'S  Artificial  Anaesthesia.  The  Advantages  and  Accidents  of  Artifi- 
cial Angesthesia  ;  Its  Employment  in  the  Treatment  of  Disease ;  Modes  of  Ad- 
ministration ;  Considering  their  Relative  Risks  ;  Tests  of  Purity  ;  Treatment  of 
Asphyxia ;  Spasms  of  the  Glottis ;  Syncope,  etc.  By  Laurence  Turnbull,  m.d., 
PH.G.,  Aural  Surgeon  to  Jefferson  College  Hospital,  etc.  Fourth  Edition,  Re- 
vised and  Enlarged.     54  Illustrations.     i2mo.  Cloth,  §2.50 

TTJSON.  Veterinary  Pharmacopceia,  including  the  outlines  of  ^Materia  ^Medica 
and  Therapeutics.  By  Richard  V.  Tusox,  late  Professor  at  the  Royal  Veter- 
inary College.  Fifth  Edition.  Revised  and  Edited  by  James  Bayxe,  F.C.S., 
Professor  of  Chemistrv  and  Toxicology-  at  the  Roval  A'eterinary  College.     i2mo. 

Cloth,  S2.25 

TT7SSEY.  Higli  Altitude  Treatment  for  Consumption.  The  Principles  or 
Guides  for  a  Better  Selection  or  Classihcation  ot  Consumptives  Amenable  to 
High  Altitude  Treatment,  and  to  the  Selection  of  Patients  who  may  be  ]\Iore 
Successfully  Treated  in  the  Environment  to  which  They  were  Accustomed 
Previous  to  Their  Illness.  By  A.  Edgar  Tussey,  m.d.,  Adjunct  Professor  of 
Diseases  of  the  Chest  in  the  Philadelphia  Polyclinic  and  School  for  Graduates 
in  ]\Iedicine,  etc.     i2mo.  Cloth,  Si. 50 

TYSON.  The  Practice  of  Medicine.  A  Text-Book  for  Physicians  and  Students, 
with  Special  Reference  to  Diagnosis  and  Treatment.  By  James  Tyson,  m.d.. 
Professor  of  Clinical  Medicine  in  the  Universit}'  of  Pennsylvania,  Physician  to 
the  University  and  to  the  Philadelphia  Hospitals,  etc.  Illustrated.  8vo.  Just 
Ready.  Cloth,  $5. 50;  Leather,  s6. 50  ;   Half  Russia,  SJ.  50 

"  Few  teachers  in  the  country  can  claim  a  longer  apprenticeship  in  the  laboratory  and  at 
the  bedside,  none  a  more  intimate  acquaintance  with  students,  since  in  one  capacity  or  another 
he  has  been  associated  with  the  University  of  Pennsylvania  and  the  Philadelphia  Hospital  for 
nearly  thirty  years.  ^loreover,  he  entered  medicine  through  the  portal  of  pathology,  a  decided 
advantage  in  the  writer  of  a  text-book.  .  .  .  The  typography  is  decidedly  above  works  of 
this  class  issued  from  our  publishing  houses.  There  is  no  American  Practice  of  the  same  attrac- 
tive appearance.  The  print  is  unusually  sharp  and  clear,  and  the  quality  of  the  paper  particu- 
larly good.  .  .  .  It  is  a  piece  of  good,  honest  work,  carefully  conceived  and  conscientiously 
carried  out.'" — University  JSIedical  Magazhie. 

*^*  Sample  Pages  and  Illustrations  Sent  Free  upon  Application. 

Guide  to  the  Examination   of  TJrine.     Ninth  Edition.     For  the  Use  of 

Physicians   and  Students.     With  Colored  Plate  and  Numerous  Illustrations 
Engraved  on  Wood.   Ninth  Edition.  Revised.   i2mo.   276  pages.    Cloth,  Si -2  5 
%*  A  French  translation  of  this  book  has  just  appeared  in  Paris. 

Handbook  of  Physical  Diagnosis.  3d  Edition.  Revised  and  Enlarged. 
With  New  Illustrations.      i2mo.  In  Press. 

Cell  Doctrine.    Its  History  and  Present  State.     Second  Edition.     Cloth,  $1.50 

UNITED    STATES    PHARMACOPCEIA.     1890,     Seventh    Decennial   Revision. 

Cloth,  S2.50  (Postpaid,  S2.77)  ;  Sheep,  S3. 00  (Postpaid,  S3.27) ;  Interleaved, 
$4.00  (Postpaid,  §4.50);  printed  on  one  side  of  page  only.  L'nbound,  S3. 50  (Post- 
paid, S3. 90). 

Select  Tables  from  the  U.  S.  P,  fl890).  Being  Nine  of  the  :\Iost  Important 
and  L'seful  Tables,  printed  on  Separate  Sheets.  Carefully  put  up  in  Patent 
Envelope.  .25 

VAN  HARLING-EN  on  Skin  Diseases.  A  Practical  Manual  of  Diagnosis  and 
Treatment  with  special  reference  to  Differential  Diagnosis.  By  Arthur  Van 
Harlingen,  m.d..  Professor  of  Diseases  of  the  Skin  in  the  Philadelphia  Poly- 
clinic ;  Clinical  Lecturer  on  Dermatology  at  Jefferson  Medical  College.  Third 
Edition.  Revised  and  Enlarged.  With  Formulse  and  lUustradons,  several  being 
in  Colors.     580  pages.  Cloth,  §2.75 

"As  would  naturally  be  expected  from  the  author,  his  views  are  sound,  his  information 

extensive,  and  in  matters  of  practical  detail  the  hand  of  the  experienced  physician  is  everywhere 

visible." — The  Medical  N'ews. 


28  P.  BLAKISTON,  SON  &^  CO.'S 

VAN  NTJYS  on  The  Urine.  Chemical  Analysis  of  Healthy  and  Diseased  Urine, 
Qualitative  and  Quantitative.  By  T.  C.  Van  Nuys,  Professor  of  Chemistry 
Indiana  University.     39  Illustrations.     Octavo.  Cloth,  $1.00 

VIRCHOWS  Post-mortem  Examinations.  A  Description  and  Explanation  of  the 
Method  of  Performing  them  in  the  Dead-House  of  the  Berlin  Charite  Hospital, 
with  especial  reference  to  Medico-legal  Practice.  By  Prof.  Virchow.  Trans- 
lated by  Dr.  T.  P.  Smith.    Illustrated.    Third  Edition,  with  Additions.    Cloth,  .75 

VOSWINKEL.  Surgical  Nursing.  A  Manual  for  Nurses.  By  Bertha  M.  Vos- 
WINKEL,  Graduate  Episcopal  Hospital,  Philadelphia;  Nurse  in  Charge  Children's 
Hospital,  Columbus,  O.     11 1  Illustrations.     i2mo.     168  pages.  Cloth,  $1.00 

WALKER.  Students'  Aid  in  Ophthalmology.  By  Gertrude  A.  Walker, 
A.B.,  M.D.,  Clinical  Instructor  in  Diseases  of  the  Eye  at  Woman's  Medical 
College  of  Pennsylvania.   40  Illustrations  and  Colored  Plate.    l2mo.   Cloth,  $1.50 

"WALSHAM.  Surgery  ;  its  Theory  and  Practice.  For  Students  and  Physicians. 
By  Wm.  J.  Walsham,  m.d.,  f.r.c.s..  Senior  Ass't  Surg,  to,  and  Dem.  of  Practi- 
cal Surg,  in,  St.  Bartholomew's  Hospital,  Surg,  to  Metropolitan  Free  Hospital, 
London.  Fifth  Edition,  Revised  and  Enlarged.  With  380  Engravings.  815 
pages.  Cloth,  $2.00  ;  Leather,  $2.50 

WARD.  Notes  on  Massage ;  Including  Elementary  Anatomy  and  Physiology. 
By  Jessie  M.  Ward,  Instructor  in  Massage  in  the  Pennsylvania,  Philadelphia, 
Jefferson,  and  Woman's  Hospitals;  Clinical  Lecturer  at  Philadelphia  Polyclinic, 
etc.     i2mo.     Interleaved.  Paper  Cover,  $1.00 

WARING.  Practical  Therapeutics.  A  Manual  for  Physicians  and  Students.  By 
Edward  J.  Waring,  m.d.  Fourth  Edition.  Revised,  Rewritten,  and  Rearranged. 
Crown  Octavo.  Cloth,  $2.00;  Leather,  $3.00 

WARREN.  Compend  Dental  Pathology  and  Dental  Medicine.  Containing  all 
the  most  noteworthy  points  of  interest  to  the  Dental  Student  and  a  Chapter 
on  Emergencies.  By  Geo.  W.  Warren,  d.d.s..  Clinical  Chief,  Penn'a  College 
of  Dental  Surgery,  Phila.  Third  Edition,  Enlarged.  Illustrated.  Bein^  No. 
13  ?  Quiz-Compend?  Series.     i2mo.  Cloth,  .80 

Interleaved  for  the  addition  of  Notes,  $1.25 
Dental  Prosthesis  and  Metallurgy.     129  Illustrations.  Cloth,  $1.25 

WATSON  on  Amputations  of  the  Extremities  and  Their  Complications.  By 
B.  A.  Watson,  m.d.     250  Illustrations.  Cloth,  $5.50 

Concussions.     An  Experimental  Study  of  Lesions  arising  from  Severe  Con- 
cussions.   8vo.  Paper  cover,  $1.00 

WELLS.  Compend  of  Gynecology.  By  Wm.  H.  Wells,  m.d..  Assistant  Demon- 
strator of  Obstetrics,  Jefferson  Medical  College,  Philadelphia ;  Fellow  of  the 
College  of  Physicians  of  Philadelphia.  1 50  Illustrations,  f  Quiz-Compend?  Series 
No.  7.     i2mo.  Cloth,  .80;  Interleaved  for  Notes,  $1.25 

WESTLAND.  The  Wife  and  Mother.  A  Handbook  for  Mothers.  By  A. 
Westland,  m.d.,  late  Resident  Physician,  Aberdeen  Royal  Infirmary.   Clo.  $1.50 

WETHERED.  Medical  Microscopy.  A  Guide  to  the  Use  of  the  Microscope  in 
Practical  Medicine.  By  Frank  J.  Wethered,  m.d.,  m.r.c.p..  Demonstrator  of 
Practical  Medicine,  Middlesex  Hospital  Medical  School;  Assistant  Physician, 
late  Pathologist,  City  of  London  Hospital  for  Diseases  of  Chest,  etc.  With  a 
Colored  Plate  and  loi  Illustrations.     406  Pages.     i2mo.  Cloth,  $2.00 

WEYL.  Sanitary  Relations  of  the  Coal-Tar  Colors.  By  Theodore  Weyl.  ' 
Authorized  Translation  by  Henry  Leffmann,  m.d.,  ph.d.     i2mo.     154  pages. 

Cloth,  $1.25 

WHITACRE.  Laboratory  Text-Book  of  Pathology.  By  Horace  J.  Whitacre, 
m.d..  Demonstrator  of  Pathology,  Medical  College  of  Ohio,  Cincinnati.  Illus- 
trated with  121  original  Illustrations.     8vo.  Cloth,  ^1.50 

WHITE.    The  Mouth  and  Teeth.     By  J.  W.  White,  m.d.,  d.d.s.  Cloth,  .40 


and  Hospital ;  Visitinf  Phvs  ciafs,   M,  t'    S*  Po^-G^duate  Medical  School 
cian  BellL„eHospi,a!.     Tfi;rE"dlon"ll,l'ou1;lT;'S'eV^e1"T.'I''''"=' ^^^''- 

With  lllusWSf:  HghS'E°dS?;  °Ln"'*  '"'  M.d.Warwickshire^England.' 

wiLbOlSr.    System  of  Human  Anatomy,    nth  Revised  Edition    Vc\\,.a^   u 

Edward    Clark  md    m  r  r  q       .i^  m     1  .       ■"•   -^-aited  by  Henry 

Glossaryof  Terms      Thi^ki2mo/^     Illustrations,  26   Colored  Places. _  and   a 


Director  of  the  Royal  UniVers^tv  HinYf  w'  P^^f^^^o*-  ^^  Gynecology  and 

Si;SSV/di{;a4'H  S^^^^^^ 

Ha„d.o.elll„s.a.io„Tr^-S-r„tfch^^e:'.rn:^^^^^^^^ 
(VTTVTTlTTr      c„  f         A      .  Cloth,  ^5.00;  Leather,  $6.00 

pSorl^'rntttrr^a^'ot  "^^^^^^^  ^^  ?•  ^^  ^^  ^^ -  -—-. 

Revised  by  T.  mTnnkrs  S™"  m  k  cT  w^thTof '  H  '  ^''^     ?^^^"^  Edition 
i2mo.  oiviiiH,  M.R.C.S.,  With  Colored  and  other  Illustrations. 

'^"i^Sis,  M^f  leL?l^j?f  I?'  ™d  Noises  in  the  Head,     By' Ebwar" 

WOAKES  MRcs    Assistam  s±f°";^T''r  ""'Pita';    assisted  by  dim 
Edition.  ■lll„sSei,?ma'^'=°"    °  ""^  London  Throat  Hospital'^    Fourth 

Diseases  of  the  Th;oa.-a;;dae°/..^Siuns.?arns°  "^  '■°"'"'"    "cfSl  '"' 
'Tke?;or.l°ats':li?ISrof  Pen^rni^-  ^^Zr'  ^^^f^ 

"'^i^^s^^.^^^s^s:ifj;^'^^^-  =^/"  H-  Woo.: ;.:: 

SSSId"^  S;^-  '"  *^  ---"sc"hlS-o?M\1ic.?i-E'„„^^^^^^^^^^ 

Materia  Medica,  aid  Offidnal  PreoaSfon,     ';^'  !'''  ''"'S'P^''   Ancles  of  the 
.7.h  Edition,  Revised.  ^  aX:^r°l«th^^S™T„«i;s^S?^.t^---S 

:oIlege,  LonLn™  axtl^'Son  -"reW^ed  Ind  e°nr°'H'K^''^.='°'°S>'  ■"  king's 
54  Wood  Engravings  and  a  GloskJ?     Crow„  Om™  """""'•  " 

Cloth,  12,50;  Leather,  J3.00 


b^oks  thaT?oCld  be  found  for  either  student  or  practitioner." 

BLAKISTON'S  ?QUIZ=COMPENDS? 

The  Best  Series  of  Manuals  for  the  Use  of  Students. 

Price  of  each,  Cloth,  .80.         Interleaved  for  taking  Notes,  $1.25. 

fi^  These  Compends  are  based  on  the  most  popular  text-books  and  the  lectures  of  promi- 
.^P.\ors   and   are  kept   constantly  revised,  so  that  they  may  thoroughly  represent  the 

college   and  contain  information  nowhere  else  collected  in  such  a  condensed,  practical  shape. 

ILLUSTRATED  CIRCULAR  FREE. 

M.    T      HUMAN  ANATOMY.         Fifth  Revised  and  Enlarged  Edition.     Including  Vis- 

""      ceralA^^oty.     Can  be  used  with  either  Morris's  or  Gray's  Anatomy.      1 17  IHustrat.ons 

X  ifi  T  i^holraohic  Plates  of  Nerves  and  Arteries,  with  Explanatory  Tables,  etc      By 

Tamukl  O   l'  Po^ER   M  D.rProfessor  of  the  Practice  of  Medicine,  College  of  Physicians 

and  Surgeons,  San  Francisco;  lateA.  A.  Surgeon,  U.S.  Army. 

1.T  PWArriCE  OF  MEDICINE.     Part  I.     Fifth  Edition,  Revised,  Enlarged,  and 

"""I'mpr^ved      By'^DANfE    H?GHKS,M.D.,  Physician  in^  Chief,  Philadelphia  Hospital,  late 

Demonstrator  of  Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia. 
No.  3.     PRACTICE  OF  MEDICINE.    Part  II.    Fifth  Edition,  Revised.  Enlarged,  and 

'  Improved.      Same  author  as  No.  2.  ,  ,  ,       r  d-      • 

ivT      .      PHYSIOLOGY      Eighth   Edition,  with  new  Illustrations  and  a  table  of  Physio- 

strLr  of  Physiology,  Jefferson  Medical  College,  Philadelphia. 

ORCSTT7TRTCS     Fifth  Edition.    By  Henry  G.  Landis,  M.D.    Revised  and  bdited 
""^  t  W°f  H    mLi":  m.d!  issiftant  DemoLtrator  of  Obstetrics,  Jefferson  Medical  College. 
PViiladplnhia      Enlarged.     47  Illustrations. 
Philaddphm^  E       g  47  THERAPEUTICS,     AND     PRESCRIPTION 

""^  WRITING      stxth  Revised  Edition  (U.  S.  P.  1890)..    By  Samuel  O.  L.  Pott-,  -n 

Professor  of  the  Practice  of  Medicine,  College  of  Physicians  and  Surgeons,  San  Francisco. 

ivT     .       rVNECOLOGY      A   New  Book.     By  Wm.  H.  Wells,  M.D.,  Assistant  Demon- 

"""Lto^IfO^SSr^Sj^erst  Medical  College,V^^  150  Illustrations 

M      R      DISEASES  OF  THE  EYE  AND  REFRACTION.     A  New  Book      Includ- 

""    •  in.  Tr  atmenfan?  SuTgery  and  a  Section  on  Local  Therapeutics.     By  George  M.GoULD 

M.D.,  and  W.  L.  Pyle,  m.d.     With  Formula,  Glossary,  several  useful  Tables,  and  li- 

Tllnstrntions    several  of  which  are  colored.  

Illustrations,  several  ^^  Bandaging.    Fifth  Edition,  Enlarged  and  Im, 

•  9-     ^      1?   o.^'tt  T  K  HoRWif  z  B  s    M  D    Clinical  Professor  of  Genito-Urinary  Surger 

Tdtener^ell  m™  in  j:SoMedS- College ;  Surgeon  to  Philadelphia  Hospital.  et< 

With  q8  Formulce  and  71  Illustrations.  ,,  .     ,     .       .    •    J 

^T       T«      MFDICAL  CHEMISTRY.     Fourth    Edition.     Including   Urinalysis,  Anims 

^°-  Ch;mi!fr?Ch?mi^trySMUk   Blood,  Tissues,  the  Secretions  etc.    By  Henry  Leffmani 

Sd      Professor  of 'Chemistr;  in    Pennsylvania  College  of  Dental   Surgery  and   in  tl 

Woman's  Medical  College,  Philadelphia.  _  ,    ^     .  t,     1     r  pu„ 

M^    TT      PHARMACY.     Fifth  Edition.    Based  upon  Prof.  Remmgton  s  Text-Book  of  Pha 

macy^^FK  STEWART,  M.D.,PH.G..  late  Quiz-Master  in  Pharmacy  and  Chemistr 

?hiladelphia  College  of  Pha;macy ;  Lecturer  at  Jefferson  Medical  College. 

_-\,^„„,T^ .  PY    ANATOMY   AND    PHYSIOLOGY.      Illustrated.      1 
"""w"    R^'bIllS.  m'^d    Prot^ro^Equ^^^  New  York  College  of  Veterin. 

S  geonsT  PhySian  to  Bellevue  Dispensary,  etc.     With  29  graphic  Illustrations^ 
M      .,      nFNTAL  PATHOLOGY  AND  DENTAL  MEDICINE.     Second  Ed.ti< 
"""lustr^tfd      c1,ntjrgXemost  noteworthy  pointsofin^ 

a  Section  on  Emergenctes.     By  Geo.  W.  Warren,  d.d.s..  Chief  of  Clinical  Staft,  Penn. 
vania  College  of  Dental  Surgery,  Philadelphia.  ,  P    H,xfti7 

T^  T.  m<=?EASES  OF  CHILDREN.  Colored  Plate.  By  Marcus  P.  Hatfie 
""^  P?ofes?or^o?DL^aL  of  ChifdJen,  Chicago  Medical  College.  Second  Edition,  Enlarge. 
T.T  r  rPTSTFRAL  PATHOLOGY  AND  MORBID  ANATOMY.  Qi  IH^st 
""^  tlons     ly  S   NE^vB^tJv  HALL.  PH.o.,  M.D.,  Professor  of  Pathology  and  Medical  Cb 

istrv   Chicago  Post- Graduate  Medical  School. 
No.  16:      DISEASES    OF   THE   SKIN.      By  Jay  F.   Schamberg,  m.d.,  Instructa 
Philadelphia  Polyclinic. 

Price,  each,  strongly  bound  in  cloth,  .80.    Interleaved  for  taking  Notes,  $L2S 


No.  9. 


Published  Annually  for  47  Years. 


The  Physicians  Visiting  List. 

(LINDSAY  &  BLAKISTON'S.) 

Special  Improved  Edition  for  1898. 


In  order  to  improve  and  simplify  this  Visiting  List  we  have  done  away  with  the  two 
styles  hitherto  known  as  the  "  25  and  50  Patients  plain."  We  have  allowed  more  space 
for  writing  the  names,  and  added  to  the  special  memoranda  page  a  column  for  the 
"Amount"  of  the  weekly  visits  and  a  column  for  the  "Ledger  Page."  To  do  this  with- 
out increasing  the  bulk  or  the  price,  we  have  condensed  the  reading  matter  in  the  front 
of  the  book  and  rearranged  and  simplified  the  memoranda  pages,  etc.,  at  the  back. 

The  Lists  for  75  Patients  and  100  Patients  will  also  have  special  memoranda  page  as 
above,  and  hereafter  will  come  in  two  volumes  only,  dated  January  to  June,  and  July  to 
December.  While  this  makes  a  book  better  suited  to  the  pocket,  the  chief  advantage  is 
that  it  does  away  with  the  risk  of  losing  the  accounts  of  a  whole  year  should  the  book 
be  mislaid. 

The  changes  and  improvements  made  in  1896  met  with  such  general 
favor  that  the  sale  Increased  more  than  ten  per  cent,  over  the  previous 
year. 


CONTENTS. 


PRELIMINARY  MATTER.— Calendar,  1 896-1897— Table  of  Signs,  to  be  used  in  keeping  records— 
The  Metric  or  French  Decimal  System  of  Weights  and  Measures — Table  for  Converting  Apothecaries' 
Weights  and  Measures  into  Grams — Dose  Table,  giving  the  doses  of  official  and  unofficial  drugs  in  both 
the  English  and  Metric  Systems — Asphyxia  and  Apnea — Complete  Table  for  Calculating  the  Period  of 
Utero-Gestation — Comparison  of  Thermometers. 

VISITING  LIST. — Ruled  and  dated  pages  for  25, 50, 75,  and  100  patients  per  day  or  week,  with  blank  page 
opposite  each  on  which  is  an  amount  column,  column  for  ledger  page,  and  space  for  special  memoranda. 

SPECIAL  RECORDS  for  Obstetric  Engagements,  Deaths,  Births,  etc.,  with  special  pages  for  Addresses 
of  Patients,  Nurses,  etc.,  Accounts  Due,  Cash  Account,  and  General  Memoranda. 


SIZES  AND    PRICES. 

REGULAR  EDITION,  as  Described  Above. 

BOUND   IN   STRONa   LEATHER  COVERS,  WITH    POCKET  AND    PENCIL. 

For  25  Patients  weekly,  with  Special  Memoranda  Page, $1  00 

50        "  "  "  «'  "         I   25 

CO        "  «  «  «  "2  vols  /  Ja""^''y  to  June     \  ^  00 

^  ■  \  July  to  December  /     •••••• 

7C        «            «               «                       «          ■     «       2  vols  /  J^°"^''y  '°  J""^    1  200 

'■'  'XJuly  to  December/ 

100        "  ««  «  "■  "        2  vols  /  ^^""^"7  '°  J""^    \  22c 

■  \  July  to  December  J ■' 

PERPETUAL  EDITION,  without  Dates. 

No.  I.  Containing  space  for  over   1300  names,  with  blank  page  opposite  each  Visiting  List  page. 

.  Bound  in  Red  Leather  cover,  with  Pocket  and  Pencil, ^i   25 

ti'o.  2.  Same  as  No.  i.     Containing  space  for  2600  names,  with  blank  page  opposite, i  5° 

f  MONTHLY  EDITION,  without  Dates. 

No,  I.  Bound,  Seal  leather,  without  Flap  or  Pencil,  gilt  edges, 75 

No.  2.  Bound,  Seal  leather,  with  Tucks,  Pencil,  etc.,  gilt  edges, i  00 

g@°  All  these  prices  are  net.     No  discount  can  be  allowed  retail  purchasers. 
Circular  and  sample  pages  upon  applicatioti. 

P.  BLAKISTON,  SON  &  CO.r  Publishers,  Philadelphia. 


JUST  PUBLISHED. 

Hemmeter.     Diseases  of  the  Stomach.    Colored 
Illustrations. 

THEIR  SPECIAL    PATHOLOGY,    DIAGNOSIS,    AND    TREATMENT.       With    Sections 

on  Anatomy,  Dietetics,  Surgery  of  Stomach,  etc.  By  John  C.  Hem- 
meter,  M.D.,  PHiLOS.D.,  Clinical  Professor  of  Medicine  at  the  Baltimore 
Medical  College,  Consultant  to  the  Maryland  General  Hospital,  etc. 
With  Colored  and  other  Illustrations,  many  of  which  are  original  and 
have  been  specially  prepared  for  this  volume.     Octavo,  778  pages. 

Cloth,  ^6.00;  Leather,  ;^7. 00 ;  Half  Russia,  ^8.00 
*5^*  This  work  has  been  prepared  with  great  care  and  forms  the  only  com- 
plete practical  text-book  in  the  English  language.  The  author  brings  to  his 
own  large  experience  a  vast  knowledge  of  the  literature  of  the  subject.  His 
chief  effort  has  been  to  furnish  the  general  practitioner  with  a  work  from 
which  he  can  readily  acquaint  himself  with  all  that  has  been  done  in  this 
important  branch  of  medicine,  to  fit  himself  to  make  examinations,  to  take 
advantage  of  new  methods  of  diagnosis,  and  to  treat  this  very  difficult  class 
of  diseases  rationally  and  successfully. 

The  illustrations  have  been  selected  and  engraved  with  great  care,  A  num- 
ber of  them  are  original;  these  have  been  drawn  by  the  author  or  prepared 
by  an  artist  under  his  immediate  directions,  and  will,  we  believe,  prove  most 
satisfactory. 

Synopsis  of  Contents. — Anatomy  and  Histology  of  the  Stomach  and 
Intestines — Physiology  of  Digestion — Pepsinogen  and  Pepsin — The  Bile — 
Formed  or  Organized  Ferments  (Bacteria)  —  Effects  of  Digestive  Secretions 
— Qualitative  and  Quantitative  Methods  for  Testing  the  Motor,  Secretory,  and 
Absorptive  Functions — Absorption  from  the  Stomach — Methods  for  Determin- 
ing the  Location,  Size,  and  Capacity  of  the  Stomach — Gastrodiaphany  of  Ein- 
horn — The  Stomach-Tube  and  Technics  of  Its  Introduction — Examination 
of  Stomach  Contents — Test-Meals — Methods  for  Qualitative  and  Quantita- 
tive Analysis  of  Stomach  Contents — Tests  for  Blood  in  Stomach  Contents — 
Examinations  of  Portions  of  Mucosa  or  Tissue  Found  in  the  Washwater 
and  Vomited  Matter — The  Diagnostic  Significance  of  Fragments  of  Mucosa 
and  of  Gastric  Exfoliations  and  Neoplastic  Tissue  Occurring  in  the  Washwater 
and  Vomited  Matter — Occurrence  of  Secretions  in  the  Empty  Stomach — 
Stimulations  to  Secretions  of  Gastric  Juice — Chemical  Examination  of  Gastric 
Juice — Quantitative  Analysis  of  the  Stomach  Acids — Dietetics — Mechanical 
Methods  of  Treatment — Uses  and  Abuses  of  Mineral  (Spring)  Waters — Alcohol 
and  Alcoholic  Beverages,  Effect  on  Digestion,  etc. — Surgical  Treatment  of  Gas- 
tric Diseases — Influence  of  Gastric  Diseases  on  Other  Organs  and  on  Metabolism 
— The  Influence  of  Diseases  of  Other  Organs  on  the  Stomach — Condition  of 
the  Urine  in  Gastric  Diseases — Acute  Gastritis — Chronic  Gastritis — Gastric 
Ulcer — Carcinoma — Sarcoma  of  the  Stomach — Syphilis  of  the  Stomach — 
Tuberculosis  of  the  Stomach — Ulcus  Carcinomatosum,  Cancerous  Ulcer  of  the 
Stomach — Benign  Tumors — Atony — Motor  Insufficiency — Dilatation — Gas- 
troptosis,  Prolapses  of  the  Stomach — Nervous  Affections  of  the  Stomach — Neu- 
roses of  Secretion — Neuroses  of  Motility.  '0 

%*  The  Sections  on  Dietetics  are  exhaustive  and  particularly  valuable  to  the 
general  practitioner. 


s> 


